Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1426

2. Registrant Information.

Registrant Reference Number: 1-28764407

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.

21-JAN-12

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW HAMPSHIRE

6. Date incident was first observed.

14-JAN-12

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. 2724-627

Product Name: Zodiac Flea and Tick Powder for Dogs, Puppies, Cats and Kittens

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1 %
  • PYRETHRINS
    • Guarantee/concentration .1 %

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7. b) Type of formulation.

Dust

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).

Caller states husband may have spilled product on arm during application in their home around January 11, 2012.

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

• Skin
  • Symptom - Rash

• General
  • Symptom - Fever

• Cardiovascular System
  • Symptom - Tachycardia
  • Symptom - Hypotension

• Blood
  • Symptom - Leukocytosis
  • Specify - blood cell count abn high WBC

• General
  • Symptom - Hypothermia

• Blood
  • Symptom - Anemia

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)

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

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

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.)

Caller's husband became symptomatic around January 14, 2012 a few days after applying product. Caller believes he may have spilled some product on his arm and did not wash it off right away. Symptoms worsened the next day so caller took him to hospital on January 15, 2012.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Husband still in hospital as of January 24, 2012. Doctors have not determined cause of his symptoms.