Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5045

2. Registrant Information.

Registrant Reference Number: 1-31451585

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.

06-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

04-SEP-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)

---

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

Product Name: Vet-Kem Siphotrol 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).

Caller inappropriately applied product to her home on September 6, 2012.

To be determined by Registrant

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

No

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

• General
  • Symptom - Loss of voice
  • Specify - difficulty speaking voice affected

4. How long did the symptoms last?

Unknown / Inconnu

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)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 applied product on September 6, 2012 in a an enclosed area with no ventilation. Caller became symptomatic after breathing in the product, she did not see a doctor and has MS. Caller used product again on September 7, she was told to move to an area with fresh air and proper ventilation and to open doors and windows. She was also informed to seek medical attention if her symptoms did not resolve within next 30 minutes or to call 911 if she developed shortness of breath or has difficulty breathing. It was suggested that she have someone else apply product for her to which she replied she has no one and the landlord won't do it.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Label precautions state not to inhale product or breathe in mist.