Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2346
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-30022252
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.
06-MAY-12
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
04-MAY-12
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. 2596-239
Product Name: UltraGuard Plus Flea Tick Collar for Puppies White
- Active Ingredient(s)
- (S)-METHOPRENE
- TETRACHLORVINPHOS
7. b) Type of formulation.
Other (specify)
Flea 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
Chihuahua
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0..25
7. Weight (provide a range if necessary )
3
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Anorexia
- General
- Symptom - Hypothermia
- Symptom - Parvovirus infection
- Specify - Parvovirus
- Symptom - Death
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?
Yes
14. b) How long was the animal hospitalized?
2
Day(s) / Jour(s)
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
1-30022252- The reporter indicated his animal was exposed to an insecticidal product containing the active ingredients tetrachlorvinphos and methoprene. The caller had placed the product on his newly acquired three month three pound spayed female Chihuahua dog three days prior to his initial call. The pet had since that point developed lethargy, vomiting, anorexia, hypothermia. The pet owner was advised of proper decontamination and to seek immediate veterinary care. On follow up the pet owner indicated the animals illness was unrelated to the use of the product. The pet had Parvo viral enteritis and had died secondary to complications associated with the infection. 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