Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-7133

2. Registrant Information.

Registrant Reference Number: 1-33727740

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.

20-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

19-MAY-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. 2724-815

Product Name: Kirkland Signature Flea and Tick Control for Dogs 13-31 lbs

• Active Ingredient(s)
  • (S)-METHOPRENE
  • ETOFENPROX
  • PIPERONYL BUTOXIDE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

3

Other Units: cc's

10. Site pesticide was applied to (select all that apply).

Site: Animal / Usage sur un animal domestique

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

May 18, 2013 caller got product on fingers while applying to dog. Caller noticed symptoms the next day on palm of hands and feet, not where caller was exposed.

To be determined by Registrant

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

Yes

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Pruritus

4. How long did the symptoms last?

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

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

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

12. Time between exposure and onset of symptoms.

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

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 got the product on her fingers while applying to her dog. She rinsed it off a few minutes afterwards. Next day caller experienced itching on palm of her hand and feet, not where she got product on her. Do not expect symptoms on areas of body not exposed to product.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.