Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-7151
2. Registrant Information.
Registrant Reference Number: 120172145
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.
14-DEC-12
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
12-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)
PMRA Registration No. 26413
PMRA Submission No.
EPA Registration No.
Product Name: Zodiac Double Action Flea And Tick Shampoo For Dogs And Cats
- Active Ingredient(s)
- (S)-METHOPRENE
- PIPERONYL BUTOXIDE
- PYRETHRINS
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: 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).
On December 10, 2012 the owner bathed the dog with the flea and tick shampoo product to treat for fleas.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Canine Domestic Unspecified Mix
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.33
7. Weight (provide a range if necessary )
30.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On December 12, 2012 the owner noticed that the dog had symptoms. On December 14, 2012 the owner contacted the Animal Product Safety Service (APSS) to obtain help; the owner thought that the dog was starting to grow some of the hair back. The APSS veterinarian stated that, especially if there were no reddening of the skin and hair seemed to be filling in again within several days, the condition would not likely be related to the use of the flea and tick shampoo product. The APSS veterinarian also stated that it was possible that the dog was starting to shed her undercoat, and after the dog was bathed with the flea and tick shampoo product, some of the fur was loosened and a large amount fell off at once. The APSS veterinarian recommended that the owner monitor the dog at home since the pet seemed to be improving and to take the dog to the veterinarian if the dog didn't get better or regrow her hair.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Signs are expected to be mild and self limiting.