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Consumer Product Safety

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
  • General
    • Symptom - Pain

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