Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1018

2. Registrant Information.

Registrant Reference Number: 1-30497965

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.

14-JUN-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MARYLAND

6. Date incident was first observed.

08-JUN-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. 2724-401-2596

Product Name: Hartz Ultraguard Plus Flea and Tick Home Spray 22 fl oz

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .01 %
  • PERMETHRIN
    • Guarantee/concentration .28 %

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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: 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).

Owner inappropriately applied product to his geriatric, diabetic dog on Thursday June 7, 2012.

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

Dog / Chien

3. Breed

Poodle

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

8

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Diarrhea

• Blood
  • Symptom - Hyperglycemia

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Treatment / Traitement

17. Provide any additional details about the incident

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

Owner inappropriately applied home spray product to geriatric, debilitated dog on June 7, 2012. The dog became symptomatic on June 8, 2012 and was brought to the vet the same day. The vet explained that his BG (blood glucose) was very high and gave him IV fluids. The dog has been diabetic since January.

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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

The dog died on June10, 2012. Label states clearly in large bold letters: DO NOT SPRAY ON PETS OR HUMANS.