Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-0819

2. Registrant Information.

Registrant Reference Number: 1-62874370

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-JAN-21

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

16-JAN-21

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. 25582      PMRA Submission No.       EPA Registration No.

Product Name: VetKem Siphotrol 2000 Double Action Premise Treatment

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .78 %
  • PERMETHRIN
    • Guarantee/concentration .8 %

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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).

Caller says that she got a drop on her foot on Jan 16 2021. She was using the product without shoes on. She reports one red spot on her foot, that she washed with water. She says the red spot is getting better.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

Skin exposure may result in irritation and redness, which should gradually subside following irrigation. Remove contaminated clothing and rinse exposed skin with water for at least 20 minutes. If skin irritation develops, apply cold compresses or vitamin E/aloe vera containing products. Symptoms expected to be mild and self-limiting.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.