Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2153

2. Registrant Information.

Registrant Reference Number: 1-39648462

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-FEB-15

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

05-JUN-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. 2724-274

Product Name: Starbar Golden Malrin Fly Bait

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
    • Guarantee/concentration .049 %
  • METHOMYL
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Granular

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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Shortness of breath

• Unknown
  • Symptom - Other
  • Specify - Heme/Hepatic blood clots in lungs and leg

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Yes

6. b) For how long?

8

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is going through a a divorce and thinks that his wife may have tried to poison him. The first time that he went to the hospital was 06/05/2014. He had not been feeling well -mainly with shortness of breath. At the hospital they discovered that he had blood clots in his lungs and legs. He was hospitalized for 8 days. He returned to the hospital on 07/24/2014 with more clots. still has shortness of breath, but he's doing better at time of reporting. Caller believes that his wife is trying to kill him because he found some of the product on the lip of one of his cans of soda (he did not drink this).

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

This product should not be added to drinking beverages for raccoons or people. This product can cause a multitude of symptoms. It is highly toxic. The symptoms are dose dependent. None of the reported symptoms are associated with a change in blood clotting or promotion of clot formation as isolated events. Caller instructed to bring MSDS to his MD for evaluation. Unclear how man was exposed.