Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4643
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-31511059
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.
12-SEP-12
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
12-SEP-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. 16673
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Flea and Tick Powder for Dogs (Canada)
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Boxer/German Shepherd mix
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.58
7. Weight (provide a range if necessary )
40
lbs
8. Route(s) of exposure
Oral
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
- Nervous and Muscular Systems
12. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
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
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-31511059 - The reporter, a veterinarian, indicated that a dog was exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The veterinarian reported that one hour prior to initial contact with the registrant the puppy chewed holes in the product bag and the powder was found spilled on the floor. The pet owner had indicated to the veterinarian that while at home the dog was drooling and seemed off balance. At the time of initial contact the reported indicated that they had induced emesis at the veterinary clinic and the puppy was currently asymptomatic. The reporter was advised to bath the dog and to give atropine if any muscarinic signs of organophosphate exposure develop. The reporter could not be reached for follow-up. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here