Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5621
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-27984417
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.
02-NOV-11
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
15-OCT-11
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. 25655
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Flea Tick Spray for Cats
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
- Nervous and Muscular Systems
- Symptom - Muscle tremors
- Symptom - Convulsions
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
1-27984417- The reporter, a pet owner, indicated her animal was exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The pet owner indicated the product was applied to her nine year male cat seventeen days prior to her initial contact with the registrant. The animal was reported to develop salivation within five minutes of application. The pet some indeterminate time following application developed vomiting, lethargy, shaking and convulsions. The pet was not brought to the veterinarian due to financial concerns but the pet owner was advised to wash the animal when she contacted her veterinary office by phone. The pet died sixteen days after application. The pet opener was advised the time line and out come were unexpected following use of the product as labeled. The pet owner was advised of registrant supported necropsy through the University of Illinois to assist in determining the cause of death. No further 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