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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2132

2. Registrant Information.

Registrant Reference Number: 100135426

Registrant Name (Full Legal Name no abbreviations): Wellmark International

Address: 100 Stone Road West, Suite 111

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G5L3

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

18-OCT-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OREGON

6. Date incident was first observed.

17-OCT-10

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-702-270

Product Name: Adams Flea and Tick Home and Carpet Spray

  • Active Ingredient(s)
    • ETOFENPROX
      • Guarantee/concentration .5 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .5 %
    • PRALLETHRIN
      • Guarantee/concentration .3 %
    • PYRIPROXYFEN
      • Guarantee/concentration .02 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

On October 17, 2010 the owner sprayed the Adams product inside the home and then waited 1.5 hours before letting the cat into the room. The owner also bathed the cat with a flea shampoo 3.5 hours after spraying the house.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Persian Cat Mix

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

9.5

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

  • Eye
    • Symptom - Pupil dilation
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Treatment / Traitement

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

On October 17, 2010 the cat developed mydriasis and then died shortly after. On October 18, 2010 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended a necropsy, contacting the flea shampoo manufacturer, and having the veterinarian call for information on the necropsy.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On October 18, 2010 the attending veterinarian contacted the APSS to discuss the necropsy. On October 19, 2010 an APSS technician contacted the attending veterinarian, who stated the cat's body was picked up on October 18 and the necropsy is pending.