Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-7771
2. Registrant Information.
Registrant Reference Number: Prosar Case 1-15324766
Registrant Name (Full Legal Name no abbreviations): The Hartz Mountain Corporation
Address: 400 Plaza Drive
City: Secaucus
Prov / State: New Jersey
Country: USA
Postal Code: 07094-3688
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
17-SEP-07
5. Location of incident.
Country: UNITED STATES
Prov / State: INDIANA
6. Date incident was first observed.
17-AUG-07
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.
Product Name: Advanced Care 3 in 1 Flea + tick Spray for Dogs - 2596-140
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .07 %
- TETRACHLORVINPHOS
- Guarantee/concentration 1.08 %
7. b) Type of formulation.
Liquid
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Lhasa Apso
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.75
7. Weight (provide a range if necessary )
3
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
Persisted until death
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?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The following report is per Customer Service representative's information) History: Caller's grandson has been applying the product to their 9 mo, 3 lb, female Lhasa Apso puppy once a week for the past 4 wks. With yesterday's application, the puppy developed vomiting, and in-coordination. The puppy died at home very early this morning. Caller disconnected before CS could transfer the call. I attempted to call the dog owner back. No answer. I left a message offering necropsy and to please call back to discuss further and in more detail. Provided case number and our telephone number.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here