Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2917
2. Registrant Information.
Registrant Reference Number: PROSAR case # 1-22597677
Registrant Name (Full Legal Name no abbreviations): The Hartz Mountain Corporation
Address: 400 Plaza Drive
City: Secaucus
Prov / State: NJ
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.
12-MAY-10
5. Location of incident.
Country: UNITED STATES
Prov / State: OKLAHOMA
6. Date incident was first observed.
10-MAY-10
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. 2596-125
Product Name: Hartz UltraGuard Flea Tick Spray for Dogs
- Active Ingredient(s)
- 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 caller specifies she sprayed her animal and rubbed him. No other information regarding application was provided.
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
Male
6. Age (provide a range if necessary )
0.58
7. Weight (provide a range if necessary )
30
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- Nervous and Muscular Systems
- Symptom - Fasciculations
- Symptom - Rigidity
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
1-22597677: The reporter, an animal owner, called on 05/12/10 to report exposure of her 7 month mixed breed dog to a pesticide containing the active ingredient Tetrachlorvinphos. The caller reported she had been using the product chronically on her animal for the past 4-5 months. She reported she had used 2.5 containers of the product on her animal in that time. She had been using the product as frequently as daily when fleas or ticks were observed on the animal. She reported she sprayed the product on her animal the evening of 05/10/10. She reported immediately the animal demonstrated fasiculations and rigidity. The animal refused food and drink and when she forced water the animal vomited. The symptoms were reported to persist until death the following morning. The owner did not seek veterinary care and no necropsy had been performed. The caller was informed that the product is well tolerated when used according to label instructions and offered assistance with necropsy to determine the cause of the animal¿s death. She did not pursue the necropsy. No other information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here