Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-0820

2. Registrant Information.

Registrant Reference Number: 1-62903597

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.

26-JAN-21

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

22-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. 25695      PMRA Submission No.       EPA Registration No.

Product Name: Zodiac Premise 2000 Flea Spray

• 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 sprayed the entire basement area of her house and had no issues at all. She then bought several more cans from a different store to treat the rest of her house. She used 1 can in all 3 bedrooms on Friday 22-JAN-2021. Caller noticed a strong chemical smell for days afterwards. She found she could not be in these rooms for more than 10 minutes without developing symptoms After she left the room she would feel better within about an hour. She applied baking soda to the carpeting and let it sit for 36 hours before vacuuming the area thoroughly and staying out of the treated area. Now the odor has subsided and she can return to the treated rooms without symptoms recurring.

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Watery eye

• Skin
  • Symptom - Burning skin

• Gastrointestinal System
  • Symptom - Other
  • Specify - Tongue going numb

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 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)

Contact with treated area

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.

Skin

Eye

Oral

Respiratory

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 and inhalation may cause a burning, itching, tingling, or numbness sensation. Symptoms typically develop soon after the exposure and resolve spontaneously within 24 hours. Ocular and respiratory irritation are also possible. There are no active recalls on this product at this time. Symptoms expected to be mild and self-limiting.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.