Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0391
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-28358270
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.
16-DEC-11
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
13-DEC-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. 2596-50
Product Name: Longlife 90 Day Flea Collar for Dogs
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
7. b) Type of formulation.
Other (specify)
collar
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
Dog / Chien
3. Breed
mixed breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.25
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
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- General
- Symptom - Polydipsia
- 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
1-28358270- The reporter, a pet owner, indicates her animal was exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The reporter applied the product to her three month male mixed breed dog six days prior to her initial contact with the registrant. The pet owner reported within three days of application the animal was observed to vomit, have diarrhea, and drink excessively. The pet owner was advised the signs seen would not be expected from use of the product according to the label. It was advised she seek immediate veterinary care. On follow up the pet owner indicated the animal had died the day following her initial contact. No treatment was provided, no veterinarian was consulted. The pet owner had animal control remove the animals remains. No necropsy had been performed. 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