Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1015

2. Registrant Information.

Registrant Reference Number: 1-27408976

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.

12-SEP-11

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

12-SEP-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)

---

PMRA Registration No. 25582      PMRA Submission No.       EPA Registration No.

Product Name: VetKem Siphotrol 2000 Double Action Premise Treatment

• Active Ingredient(s)
  • (S)-METHOPRENE
  • PERMETHRIN

---

7. b) Type of formulation.

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).

Product was sprayed in home on September 12, 2011.

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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Numbness

• General
  • Symptom - Swelling

• Gastrointestinal System
  • Symptom - Irritated throat
  • Specify - throat irritation

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

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)

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Caller became symptomatic after spraying product in home. Caller reports a history of asthma but denies any breathing or swallowing difficulties at this time. Caller does not remember getting product on her skin. She was instructed to remove contaminated clothing and get into the shower for full dermal decontamination, rinse face and exposed skin off for 20 minutes. She was also instructed to call for medical attention should any symptoms persist.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Follow up call was placed on September 13th, 2011. Caller stated that she is better today. Symptoms had completely resolved within a few hours. She did seek medical attention and was treated with Benedryl.