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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5658

2. Registrant Information.

Registrant Reference Number: 1-26484010

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

Address: 100 STONE ROAD WEST, SUITE 111


Prov / State: ON

Country: CANADA

Postal Code: N1G 5L3

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


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: NEW YORK

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-401-2596

Product Name: Hartz UltraGuard Plus Flea and Tick Home Spray

  • Active Ingredient(s)
      • Guarantee/concentration .01 %
      • Guarantee/concentration .28 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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).

The caller sprayed the carpets with the product on June 12th, 2011.

To be determined by Registrant

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


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

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • General
    • Symptom - Lightheadedness
  • Eye
    • Symptom - Double vision
  • Nervous and Muscular Systems
    • Symptom -
    • Specify - aneurism on his brain
  • Cardiovascular System
    • Symptom - Stroke
    • Specify - mini stroke

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


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

Contact with treated area

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


10. Route(s) of exposure.


11. What was the length of exposure?

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

12. Time between exposure and onset of symptoms.

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

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 June 13th caller's father became symptomatic after being exposed to previously treated area. Caller expressed that product had an unpleasant odor and is currently ventilating the home. Father is a past smoker with a smoker's cough and has a history of high cholesterol. He was sent to the emergency room. Our specialist explained that patients who smoke or have underlying respiratory conditions may experience more pronounced symptoms that require medical attention. Caller was instructed to ventilate the area by opening outside doors and windows and to consider adding portable fans until the odor dissipated. Caller was instructed to discard product as it should not have a strong odor.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

During time in hospital on June 13th, 2011 caller's father was diagnosed as having had a mini stroke and was still in hospital on June 15th going through more tests and appears to have an aneurism on his brain. Caller is having carpets removed from the house as odor is still strong. Customer service asked her to return product so they could test it but she refused as did not want to send through the mail and wishes to have product tested locally. A stroke is not an expected effect from exposure to the odor of the product.