Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-1824
2. Registrant Information.
Registrant Reference Number: 1-31719258
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.
05-OCT-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
29-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.
Product Name: Vet-Kem Siphotrol 2000 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).
Product was sprayed in home around September 18th, 2012 and again around September 28th to other parts of the home.
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.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Respiratory System
- Symptom - Shortness of breath
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)
Contact with treated area
Amount of time between application and contact 7
Day(s) / Jour(s)
What was the activity? sleeping in treated bedroom
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?
>1 wk <=1 mo / > 1 sem < = 1 mois
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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 became symptomatic after sleeping in bedroom which was treated for fleas one week ago. Suggestions were made to aerate the home.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Signs expected to be mild and self limiting.
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
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)
Contact with treated area
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.
Unknown
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
Wife had mild symptoms after product was applied initially but symptoms have resolved. She believes the treated area was not vented properly causing her symptoms.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Signs expected to be mild and self limiting