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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-0769

2. Registrant Information.

Registrant Reference Number: 180187111

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.

08-NOV-18

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

08-NOV-18

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. 2724-808-270

Product Name: Adams Plus Flea And Tick Indoor Fogger Can

  • Active Ingredient(s)
    • (S)-METHOPRENE
      • Guarantee/concentration .09 %
    • ETOFENPROX
      • Guarantee/concentration .5 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .5 %
    • TETRAMETHRIN
      • Guarantee/concentration .4 %

7. b) Type of formulation.

Other (specify)

Total Release Fogger

Application Information

8. Product was applied?

Yes

9. Application Rate.

3

Other Units: 1- 3 ounce can

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 November 8, 2018, the owner set the fogger off inside the home. it is unclear if the aquarium air flow system was turned off before fogging.

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

Fish / Poisson

3. Breed

African Cichlids

4. Number of animals affected

4

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

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

A few hours after setting off the fogger, the owner returned home and noticed that four fish in the tank were dead. The owner then contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that fish are very sensitive to pyrethroids and exposure can result in death. The APSS assistant recommended the owner call back with questions.


To be determined by Registrant

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

Death

19. Provide supplemental information here

At the time of this report, a necropsy is not pending. It is unclear if the aquarium air flow system was turned off before fogging.