Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2261

2. Registrant Information.

Registrant Reference Number: 1-37024814

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.

06-MAY-14

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

06-MAY-14

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. 2724-809-89459

Product Name: Bio Spot Active Care Flea and Tick Carpet Spray

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .045 %
  • ETOFENPROX
    • Guarantee/concentration .5 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .5 %
  • PRALLETHRIN
    • Guarantee/concentration .3 %

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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 May 6 2014 callers husband applied product in home with some windows open.

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Stomach pain
  • Specify - Abdominal pain
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Headache

• Skin
  • Symptom - Pallor

• Gastrointestinal System
  • Symptom - Other
  • Specify - partial bowel obstruction

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.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

3

Day(s) / Jour(s)

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

On May 6 2014 caller's husband applied product to the home and developed symptoms within 3 hours. Some windows were open during application, remainder of windows opened since application. May 8 2014 caller's husband stated he was diagnosed with a partial bowel obstruction, spent 3 days in hospital and said his symptoms were totally unrelated to the product.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.