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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2756
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-30430699
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.
08-JUN-125. Location of incident.
Country: UNITED STATES
Prov / State: MARYLAND
6. Date incident was first observed.
08-JUN-12Product 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 and Tick Spray for Dogs 16 fl oz
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .07 %
- TETRACHLORVINPHOS
- Guarantee/concentration 1.08 %
- (S)-METHOPRENE
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
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
12
7. Weight (provide a range if necessary )
8.2
lbs
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
- General
- Symptom - Lethargy
- Gastrointestinal System
- Symptom - Anorexia
- Nervous and Muscular Systems
- Symptom - Shaking
- Gastrointestinal System
- Symptom - Vomiting
- Blood
- Symptom - Hyperglycemia
- General
- 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?
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
1-30430699- The reporter, a veterinarian, indicated a patient had been exposed to an insecticide containing the active ingredient tetrachlorvinphos. The reporter indicated she was attending to a twelve year male eight pound mixed breed diabetic dog. The veterinarian indicated the animals previously diagnosed diabetes was poorly regulated and she believed the animals current health issues were related to the endocrine disease rather than the use of the product. The pet owner had applied the product two days prior to her report and applied again the subsequent day. The animal presented the day of the report with the primary complaint of lethargy, anorexia, shaking, and vomiting. The veterinarian added the animal was hyperglycemic. The reporter was advised the signs seen would not be expected following use per the label. She was advised the product was not labeled for use on debilitated or ill animals. She was provided instructions on decontamination but advised to investigate other etiology. On follow up the registrant was informed the animal had died three days later. No necropsy was planned. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
