Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6459

2. Registrant Information.

Registrant Reference Number: 130123188

Registrant Name (Full Legal Name no abbreviations): Wellmark International

Address: 100 Stone Road West, Suite 111

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G5L3

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

02-SEP-13

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSOURI

6. Date incident was first observed.

02-SEP-13

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. 2724-774-270

Product Name: Adams Inverted Carpet Spray With Linalool And Nylar

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 1 %
  • PERMETHRIN
    • Guarantee/concentration .2 %
  • PYRIPROXYFEN
    • Guarantee/concentration .015 %

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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).

On September 1, 2013 the owner sprayed the product on the dog's bedding area and around the house to treat for fleas. The dog may have been exposed to some of the product.

To be determined by Registrant

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

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever Mix

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.42

7. Weight (provide a range if necessary )

25.0

lbs

8. Route(s) of exposure

Skin

Oral

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 - Drooling

• General
  • Symptom - Lethargy
  • Symptom - Listless

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Anorexia

• Eye
  • Symptom - Pupil dilation

• General
  • 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

On the morning of September 2, 2013 the owner noticed that the dog was symptomatic. Later that day the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that the main concern was for gastrointestinal (GI) upset, a taste reaction from ingestion the APSS veterinarian suspected that something else might be going on with the dog. The APSS veterinarian recommended that the owner bathe the dog with a liquid dish washing detergent (LDWD), take the dog to a veterinarian, and have the veterinarian call for information.

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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 APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On September 4, 2013 an APSS assistant called the owner to update the case. The owner stated that at an unknown time he bathed the dog, monitored the dog at home, called a veterinarian, and gave the dog a clove of garlic as directed by the veterinarian he consulted with. Garlic ingestion by a dog can be life threatenting.The owner stated that the dog died on September 3, 2013. A necropsy was not available. The APSS assistant told the owner he could call back with questions regarding the case.