Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1015

2. Registrant Information.

Registrant Reference Number: 1-30147969

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.

Domestic Animal

4. Date registrant was first informed of the incident.

16-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

15-MAY-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. 2724-777-2596

Product Name: Hartz Ultraguard Plus Flea and Tick Carpet Powder

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PYRETHRINS
    • Guarantee/concentration .075 %
  • PYRETHRINS
    • Guarantee/concentration .075 %

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7. b) Type of formulation.

Other (specify)

powder

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 applied inside of home in dining room, living room and hallway but was not vacuumed up oer label directions on May 15, 2012. Kittens were exposed to treated area.

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

Cat / Chat

3. Breed

unknown

4. Number of animals affected

2

5. Sex

Unknown

6. Age (provide a range if necessary )

0.08

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

Unknown

9. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Respiratory System
  • Symptom - Laboured breathing

• General
  • Symptom - Vocalizing
  • Specify - meow was different
  • 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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Owner applied product inside of home on May 15, 2012. She did not follow label directions which stated to: Leave on for two hours, then thoroughly vacuum to remove all insecticidal product. Kittens were brought in the room and allowed on furniture and carpets after product was freshly applied and not vacuumed. Kittens became symptomatic a few hours later and died.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

Label directions state: Do not apply this product in a way that will contact adults, children or pets, either directly or through drift.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Cat

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

0.08

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

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

• Nervous and Muscular Systems
  • Symptom - Ataxia

• General
  • Symptom - Lethargy
  • 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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

wner applied product inside of home on May 15, 2012. She did not follow label directions which stated to: Leave on for two hours, then thoroughly vacuum to remove all insecticidal product. Kittens were brought in the room and allowed on furniture and carpets after product was freshly applied and not vacuumed. kitten became symptomatic a few hours later and died.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

Label directions state: Do not apply this product in a way that will contact adults, children or pets, either directly or through drift.