Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5926

2. Registrant Information.

Registrant Reference Number: 1-32010897

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.

07-NOV-12

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

Unknown

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. 2724-404-270

Product Name: Adams Plus Flea and Tick Mist with Precor

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .27 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .62 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .37 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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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: Animal / Usage sur un animal domestique

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller applied product to cats one week ago, approximately October 30th, 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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Other
  • Specify - not breathing

• Renal System
  • Symptom - Dialysis required
  • Specify - kidneys affected, on dialysis

• Respiratory System
  • Symptom - Respiratory distress
  • Specify - low oxygenation
  • Symptom - Other
  • Specify - lung inflammation
  • Symptom - Respiratory failure

• General
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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)

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.

Skin

11. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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 3 or 4 days after product was applied to cats around October 30, 2012. Caller reported that her husband has an auto immune disorder and is currently ill and was admitted to ICU. He became ill during the weekend, she indicated he may have touched a cat and that the product may have penetrated his skin. Caller was very distracted and history collection was difficult. Husband was not breathing on the weekend and was admitted to critical care. His oxygen was low, he was placed on a ventilator and given anti-inflammatory medications. She indicated he had inflammation in his lungs. He was progressively weaned off of the ventilator and was at 30% which was good. His breathing was bad and had to go on dialysis as his kidneys were affected. Caller explained she was just covering her bases and collecting MSDS sheets for the doctors treating her husband. Caller was given information and told that that it would be highly unusual for this product to be related to her husband's illness as the level of exposure by petting a cat to which this product was applied would be very low.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

Caller's husband passed away on (date). Exact cause of death was unknown. His lungs were inflamed causing pulmonary failure.