Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-0784
2. Registrant Information.
Registrant Reference Number: 130160250
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.
19-NOV-13
5. Location of incident.
Country: UNITED STATES
Prov / State: KANSAS
6. Date incident was first observed.
18-NOV-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 2724-274
Product Name: Starbar Golden Malrin Fly Bait 1% Methomyl
- Active Ingredient(s)
- (Z)-9-TRICOSENE
- Guarantee/concentration .049 %
- METHOMYL
- Guarantee/concentration 1 %
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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
Canine Domestic Unspecified
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
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
Died
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On an unspecified date and time the owner noticed that the dog was able to knock the bait product off of a tall shelf and accidentally ingest an unknown amount of the bait product. On November 18, 2013 the owner observed that the dog had died. On November 19, 2013 the owner contacted the company to obtain help. The company's veterinarian stated that the risk was for salivation, lacrimation, urination, defecation, dyspnea, and emesis (SLUDDE) signs progressing rapidly to tremors, seizures, dyspnea, bradycardia, and death. A necropsy was not available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here