Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-6043
2. Registrant Information.
Registrant Reference Number: 1-61997766
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.
Human
4. Date registrant was first informed of the incident.
18-AUG-20
5. Location of incident.
Country: CANADA
Prov / State: UNKNOWN
6. Date incident was first observed.
18-AUG-20
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. 25582
PMRA Submission No.
EPA Registration No.
Product Name: VetKem Siphotrol 2000 DOuble Action Premise Treatment
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .078 %
- PERMETHRIN
- Guarantee/concentration .8 %
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: 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).
At 10 am on Aug 18th 2020, the caller sprayed the product in multiple rooms, using a large amount of spray.
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
- Gastrointestinal System
- Symptom - Other
- Specify - Numb Tongue
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
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)
Unknown
10. Route(s) of exposure.
Respiratory
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 said he is experiencing symptoms after spraying. Caller should be removed to a well-ventilated area and the area treated should be ventilated as well. Symptoms expected to be mild and self-limiting.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.