Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2717
2. Registrant Information.
Registrant Reference Number: Prosar 1-18843098
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.
16-JUN-09
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
14-JUN-09
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. 2596-140
Product Name: Advanced Care 3 in 1 Dog Spray 16 fl oz
- 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).
The product was applied to the dog on 06/13/2009.
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 Breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
20
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Difficulty walking
- Symptom - Difficulty getting up
- Specify - "Unable to stand"
- Symptom - Ataxia
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
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
1-18843098: A reporter (dog owner) called on 06/16/2009 to report the exposure of her dog to a flea and tick spray containing the active ingredients Methoprene and Tetrachlorvinphos. According to the reporter, the product was applied to the dog on 06/13/2009. On 06/14/2009, the dog was unable to stand or walk, ataxic, and having vomiting and diarrhea. At an unknown point following the development of signs, the reporter attempted to wash the product off using a washcloth, water, and Dove soap. The dog was not evaluated by a veterinarian and died on 06/16/2009. The reporter was advised that the signs described are not expected with labelled product use. A recommendation was made to consider necropsy to determine the cause of death as other causes may be responsible for the signs. No further information was obtained.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here