Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-0048
2. Registrant Information.
Registrant Reference Number: 150126900
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-SEP-15
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
13-SEP-15
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. 25739
PMRA Submission No.
EPA Registration No.
Product Name: Vet Kem Siphotrol 1000 Double Action Premise Treatment
- Active Ingredient(s)
- (S)-METHOPRENE
- PERMETHRIN
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 September 11, 2015 the dog was taken to the groomer and given a flea bath and the groomer applied a topical product (the owner is unsure what products were used at the groomer). On that same day, the owner applied the Vet Kem product to her baseboards and around the pet bedding.
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
Tibetan Spaniel
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.0
7. Weight (provide a range if necessary )
10.0
lbs
8. Route(s) of exposure
Skin
Oral
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
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
- Eye
- Symptom - Protrusion of the third eyelid
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 13, 2015 the dog developed agitation. On September 14, 2015 the dog developed vomiting, diarrhea, lethargy, protrusion of the third eyelid, and anorexia. Later that day, the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated the risk is for mild dermal sensitivity and gastrointestinal (GI) upset. The APSS technician recommended taking the dog to the veterinarian, having the veterinarian call for information, and calling back with questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Signs were expected to be mild and self-limiting.