Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4966
2. Registrant Information.
Registrant Reference Number: Prosar case 1-16332965
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.
27-JUN-08
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH DAKOTA
6. Date incident was first observed.
09-JUN-08
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. 2596-139
Product Name: 3 in 1 Reflecting Control Collar for Dogs
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration 1.02 %
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
7. b) Type of formulation.
Other (specify)
Treated Collar
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).
The product was applied about 3 weeks prior to the call (estimated 6/6/08).
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
Dog / Chien
3. Breed
Mixed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
29
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
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Abnormal behaviour
- Specify - "extra happy"
- Renal System
- Symptom - Lack of control of urination
- Nervous and Muscular Systems
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
5
Day(s) / Jour(s)
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
1-16332965: The reporter called on 6/27/08 to report the application of a flea and tick collar containing the active ingredients Tetrachlorvinphos and Methoprene to her 7 year old male dog approximately 3 weeks previously. According to the reporter, the dog had become ¿¿¿extra-happy¿¿¿ shortly after the collar had been applied. About 10 days after application, the dog had become incontinent. Then on 6/23, the reporter had found the dog ataxic. He had been taken to a veterinarian and had remained there ever since with no change in symptoms. During the 6/27 call, the potential use of atropine as well as the company sponsored cholinesterase testing program were discussed. A recommendation was made to have the attending veterinarian call regarding treatment and organophosphate testing. A follow-up call revealed the dog had passed away on 6/27.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here