Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5651

2. Registrant Information.

Registrant Reference Number: 1-27719533

Registrant Name (Full Legal Name no abbreviations): WELLMARK INTERNATIONAL

Address: 100 STONE ROAD WEST, SUITE 111

City: GUELPH

Prov / State: ON

Country: CANADA

Postal Code: N1G 5L3

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

Human

4. Date registrant was first informed of the incident.

17-OCT-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

14-OCT-11

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-274

Product Name: Starbar Golden Malrin Fly Bait

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
    • Guarantee/concentration .049 %
  • METHOMYL
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

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

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Muscle spasm
  • Specify - muscle spasms in face and neck

• Eye
  • Symptom - Other
  • Specify - left eye closed

• Respiratory System
  • Symptom - Other
  • Specify - respiratory arrest

• Eye
  • Symptom - Blurred vision

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Eye

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

On October 10th and October 14th caller's father was crushing and mixing the product with water and at times with his bare finger. Later in the day on October14th father became symptomatic and was taken to the ER. He later went into respiratory arrest and was intubated and admitted to ICU. The breathing tube was removed on October 17th. Father also has vision issues with his left eye. Symptoms are improving however physicians have run all kinds of tests on his father and they are coming up with no answers.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Caller agreed product was being used off label and inappropriately. MSDS sheets were faxed and it was recommended that he continue to work with physicians for appropriate treatment. Symptoms are improving however physicians have run all kinds of tests on his father and they are coming up with no answers. many follow up calls were made to update the case however there has been no reply to date.