Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2919
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-22644252
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.
17-MAY-10
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
15-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. Unknown
Product Name: UltraGuard Flea Tick Powder for Dogs
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 3.3 %
7. b) Type of formulation.
Dust
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 a dog. No other information about application is available.
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 )
1.5
7. Weight (provide a range if necessary )
15
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
- Symptom - Vomiting
- Symptom - Diarrhea
- Symptom - Anorexia
- General
- Symptom - Lethargy
- Symptom - Death
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
1-22644252- The reporter calls to indicates her dog was exposed to an insecticide containing the active ingredient Tetrachlorvinphos. The caller stated she applied the product to her 1.5 year 15 pound mixed breed dog 05/14/10 in the evening. The next day the animal demonstrated signs of lethargy, vomiting, and diarrhea. Excessive salivation and anorexia was also reported. The caller was advised to wash her animal with a non-insecticidal shampoo and transport to the veterinarian for treatment of symptoms and to investigate potential etiology of signs developed. The caller was offered of cholinesterase testing through the veterinarian to determine any relationship between observed signs and exposure to the product. On routine call back it was reported the animal had died the morning of the initial call. The caller had not sought veterinary care. 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