Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5628
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-27838826
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.
24-OCT-11
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
23-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.
PMRA Submission No.
EPA Registration No. 2596-140
Product Name: UltraGuard Plus Flea Tick Spray for Cats
- 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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
11
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
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Death
- Symptom - Vocalizing
- Nervous and Muscular Systems
- Symptom - Difficulty walking
- Renal System
- Symptom - Low urine output
- Respiratory System
- Symptom - Heavy breathing
- Nervous and Muscular Systems
- Symptom - Muscle weakness
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
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
1-27838826- The reporter, a pet owner, indicated her animal had been exposed to an insecticidal product containing the active ingredients tetrachlorvinphos and methoprene. The pet owner stated she applied the product to her eleven year male domestic shorthair cat three weeks and one week prior to her initial contact with the registrant. The reporter indicated the animal one week after the subsequent application developed the signs of lethargy, weakness, pain, vocalizing, he was having difficulty breathing, and breathing heavily. The animal died later that night and its remains brought to the veterinarian. The caller revealed the animal was seen in the liter box straining to urinate prior to its death. The pet owner was advised the signs seen, time line, and out come were inconsistent with the use of the product as labeled. The pet owner was advised of registrant supported necropsy through the University of (name) to assist in determining the cause of death. The pet owner did not submit the animal for necropsy. 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