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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4175
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-31180902
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.
10-AUG-125. Location of incident.
Country: UNITED STATES
Prov / State: WISCONSIN
6. Date incident was first observed.
06-AUG-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. 2596-78
Product Name: UltraGuard Flea and Tick Powder for Cats
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 3.3 %
- TETRACHLORVINPHOS
7. b) Type of formulation.
Dust
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
Cat / Chat
3. Breed
Domestic Longhair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Weight loss
- Nervous and Muscular Systems
- Symptom - Agitation
- General
- 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?
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
1-31180902 - The reporter, a pet owner, indicated that her cats were exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The pet owner reported that the product was applied to her 5-year-old, male, domestic longhaired cat (Subform III #1) and her 2.5-year-old, male cat (Subform III #2) five days prior to initial contact with the registrant. The following day the reporter indicated that both cats were freaking out. The reporter spoke with her veterinarian and per the veterinarians suggestion the reporter bathed both cats that day using dawn dish soap. The next day the reporter found her 5-year-old cat dead. At the time of initial contact caller indicated that her 2.5-year-old cat was lethargic. Caller was advised that the product is typically well tolerated by cats, decontamination is recommended if any unexpected symptoms develop. Caller was further advised to seek medical attention for your 2.5 year old cats ongoing lethargy: Lethargy is a non-specific symptom with many possible causes and requires medical evaluation for appropriate treatment. 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
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Mixed breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2.5
7. Weight (provide a range if necessary )
8.5
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Lethargy
- Nervous and Muscular Systems
- Symptom - Agitation
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
1-31180902 - The reporter, a pet owner, indicated that her cats were exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The pet owner reported that the product was applied to her 5-year-old, male, domestic longhaired cat (Subform III #1) and her 2.5-year-old, male cat (Subform III #2) five days prior to initial contact with the registrant. The following day the reporter indicated that both cats were freaking out. The reporter spoke with her veterinarian and per the veterinarians suggestion the reporter bathed both cats that day using dawn dish soap. The next day the reporter found her 5-year-old cat dead. At the time of initial contact caller indicated that her 2.5-year-old cat was lethargic. Caller was advised that the product is typically well tolerated by cats, decontamination is recommended if any unexpected symptoms develop. Caller was further advised to seek medical attention for your 2.5 year old cats ongoing lethargy: Lethargy is a non-specific symptom with many possible causes and requires medical evaluation for appropriate treatment. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
