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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5665
2. Registrant Information.
Registrant Reference Number: 110127108
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.
03-OCT-115. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
6. Date incident was first observed.
22-SEP-11Product 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. 2724-483
Product Name: Zodiac Fleatrol Carpet And Upholstery Aerosol Spray
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .09 %
- PERMETHRIN
- Guarantee/concentration .5 %
- (S)-METHOPRENE
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 September 21, 2011 the owner sprayed the product in his home, potentially exposing 4 salt water fish and 3 fresh water fish to the product.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
Salt water fish
4. Number of animals affected
3
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- 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?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 22, 2011 the owner found that 4 salt water fish and 3 fresh water fish had died. At an unknown date and time the owner changed the water in the salt water tank and in the fresh water tank. On October 3, 2011 the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that permethrin is toxic to fish, but that with appropriate use of the product, problems would not be expected. The APSS veterinarian also stated that attempting to test the water or fish could be helpful in determining the cause of death. The APSS veterinarian recommended that the owner call back with questions.
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 an unknown likelihood of causing the clinical situation.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
Salt water fish
4. Number of animals affected
4
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- 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?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 22, 2011 the owner found that 4 salt water fish and 3 fresh water fish had died. At an unknown date and time the owner changed the water in the salt water tank and in the fresh water tank. On October 3, 2011 the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that permethrin is toxic to fish, but that with appropriate use of the product, problems would not be expected. The APSS veterinarian also stated that attempting to test the water or fish could be helpful in determining the cause of death. The APSS veterinarian recommended that the owner call back with questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
