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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4346

2. Registrant Information.

Registrant Reference Number: 1-40729788

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

Domestic Animal

4. Date registrant was first informed of the incident.

28-MAY-15

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

Unknown

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. 2724-485-270

Product Name: Adams Plus Flea Tick Shampoo with Precor 12 oz

Active Ingredient(s)
- (S)-METHOPRENE
  - Guarantee/concentration .016 %
- PIPERONYL BUTOXIDE
  - Guarantee/concentration 1.88 %
- PYRETHRINS
  - Guarantee/concentration .015 %

7. b) Type of formulation.

Liquid

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).

Caller initially purchased this product about 2 years ago for a stray cat. They used it on the cat after a couple of months.

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

Skin
- Symptom - Erythema
- Symptom - Burns (superficial)
- Specify - dermal almost like a chemical burn

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?

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)

Chemical resistant gloves

10. Route(s) of exposure.

Skin

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.)

Caller used this about 2 months ago on her dogs. She is diabetic and has thin skin, so she wore gloves. She splashed some of this above her gloves. She rinsed for a very long time with water. She has been to the doctor.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Symptoms typically develop soon after the exposure and resolve spontaneously within 24 hours. We do not expect any visible change to the skin.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

Nervous and Muscular Systems
- Symptom - Seizure

General
- Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

14. a) Was the animal hospitalized?

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

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

Caller initially purchased this product about 2 years ago for a stray cat. They used it on the cat after a couple of months.

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Incident Report

Subform I: General Information

1. Report Type.

2. Registrant Information.

3. Select the appropriate subform(s) for the incident.

4. Date registrant was first informed of the incident.

5. Location of incident.

6. Date incident was first observed.

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.

7. b) Type of formulation.

Application Information

8. Product was applied?

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?

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

1. Source of Report.

2. Demographic information of data subject

3. List all symptoms, using the selections below.

4. How long did the symptoms last?

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

6. a) Was the person hospitalized?

6. b) For how long?

7. Exposure scenario

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)

10. Route(s) of exposure.

11. What was the length of exposure?

12. Time between exposure and onset of symptoms.

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.)

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

2. Type of animal affected

3. Breed

4. Number of animals affected

5. Sex

6. Age (provide a range if necessary )

7. Weight (provide a range if necessary )

8. Route(s) of exposure

9. What was the length of exposure?

10. Time between exposure and onset of symptoms

11. List all symptoms

12. How long did the symptoms last?

13. Was medical treatment provided? Provide details in question 17.

14. a) Was the animal hospitalized?

14. b) How long was the animal hospitalized?

15. Outcome of the incident

16. How was the animal exposed?

17. Provide any additional details about the incident

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

19. Provide supplemental information here