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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1041

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24939552

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.

Human

Domestic Animal

4. Date registrant was first informed of the incident.

11-DEC-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

11-DEC-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. 25620      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea Tick Collar for Dogs

  • Active Ingredient(s)
    • TETRACHLORVINPHOS

7. b) Type of formulation.

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?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Stomach pain
  • Respiratory System
    • Symptom - Irritated throat

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-24939552- The reporter, a pet owner, indicates he and his animal were exposed to a pesticide containing the active ingredient tetrachlorvinphos. The pet owner stated he applied the product, a flea and tick collar, to his eight week twenty pound golden retriever three days prior to his initial contact with the registrant. The pet owner stated the animal demonstrated the signs loss of appetite, vomiting and was lying on her side shaking the day of initial contact. The pet owner also indicated he had touched the collar the day of application and had smoked a cigarette soon thereafter. He, the day of initial contact, had developed the symptoms of abdominal pain, and throat irritation. The pet owner was advised the exposure both to himself and his pet would not be expected to elicit the symptoms seen. He was advised to remove the collar from his pet and seek immediate veterinary care. He was likewise advised to seek a medical assessment for himself. On routine follow up a female in the home stated the animal was improved, it was not brought to the veterinarian. She refused to provide further information citing a shortage on her cellular phone minutes. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

golden retiever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.15

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

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Vomiting
  • Nervous and Muscular Systems
    • Symptom - Recumbent
    • Symptom - Shaking

12. How long did the symptoms last?

Unknown / Inconnu

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

Fully Recovered / Complètement rétabli

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

1-24939552- The reporter, a pet owner, indicates he and his animal were exposed to a pesticide containing the active ingredient tetrachlorvinphos. The pet owner stated he applied the product, a flea and tick collar, to his eight week twenty pound golden retriever three days prior to his initial contact with the registrant. The pet owner stated the animal demonstrated the signs loss of appetite, vomiting and was lying on her side shaking the day of initial contact. The pet owner also indicated he had touched the collar the day of application and had smoked a cigarette soon thereafter. He, the day of initial contact, had developed the symptoms of abdominal pain, and throat irritation. The pet owner was advised the exposure both to himself and his pet would not be expected to elicit the symptoms seen. He was advised to remove the collar from his pet and seek immediate veterinary care. He was likewise advised to seek a medical assessment for himself. On routine follow up a female in the home stated the animal was improved, it was not brought to the veterinarian. She refused to provide further information citing a shortage on her cellular phone minutes. No further information is available.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Moderate

19. Provide supplemental information here