Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2357

2. Registrant Information.

Registrant Reference Number: 1-32245011

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-DEC-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

09-DEC-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. 2724-702-270

Product Name: Adams Flea and Tick Home and Carpet Spray 16 fl oz

• Active Ingredient(s)
  • ETOFENPROX
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PRALLETHRIN
  • PYRIPROXYFEN

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7. b) Type of formulation.

Other (specify)

aerosol

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).

Caller mistakenly sprayed his can of pop while treating his home on December 9, 2012.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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

• General
  • Symptom - Sweating

• Gastrointestinal System
  • Symptom - Vomiting

• Respiratory System
  • Symptom - Respiratory irritation

• General
  • Symptom - Pain
  • Specify - right arm pain

• Cardiovascular System
  • Symptom - Other
  • Specify - heart attack

• Respiratory System
  • Symptom - Irritated throat
  • Specify - throat irritation

4. How long did the symptoms last?

Unknown / Inconnu

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)

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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 accidentally sprayed product over his can of pop on December 9, 2012. Drank from pop can exposed to spray. He became symptomatic seven hours later. Caller was using treadmill when symptoms began. Our specialist informed caller to seek medical attention as he was worried caller may be experiencing cardiac symptoms and not a reaction to product exposure. Caller was also advised to call 911 if arm pain persisted or radiated or became diaphoretic again with nausea. The caller went to hospital and was diagnosed with a heart attack.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Follow up call was made on December 11, 2012. Spoke to caller's daughter, he had gone to hospital and was diagnosed with a heart attack. A stent was placed and he is doing well.