Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1828

2. Registrant Information.

Registrant Reference Number: 1-32027272

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.

09-NOV-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

22-OCT-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. Unknown

Product Name: Vet-Kem Siphotrol Double Action Premise Treatment

• Active Ingredient(s)
  • (S)-METHOPRENE
  • PERMETHRIN

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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: Pub. Area - Indoor/Zone publique - int

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

Product was sprayed in one room of a clinic on October 22, 2012. Door was kept shut after room was sprayed.

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

• Respiratory System
  • Symptom - Difficulty Breathing

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness
  • Symptom - Difficulty talking

• General
  • Symptom - Other
  • Specify - allergies

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Drift from the application site

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?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 being exposed to scent of product on October 22nd 2012. Caller said she has allergies and is ultra sensitive to fragrances. She believed she was having an allergic reaction to the product. She went outside for an hour and symptoms improved, when she re-entered clinic symptoms began again. Caller is allergic to OTC and prescription medications, she took 1/2 tsp of oral Benedryl. Caller saw her own MD on October 23, 2012 and she was given a juvenile Epi pen as adult version is too strong for her. Caller returned to work on October 24, 2012.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Signs expected to be mild and self limiting. Caller was not sure which product was used.