Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4979
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-31813162
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.
17-OCT-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
16-OCT-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. 30181
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Plus Flea/Tick Dog Spray with Aloe
- Active Ingredient(s)
- (S)-METHOPRENE
- TETRACHLORVINPHOS
7. b) Type of formulation.
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
Bulldog
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
89
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
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
1-31843583 - The reporter, a pet owner, indicated that her dog was exposed to an insecticidal product containing the active ingredients methoprene and tetrachlorvinphos. The pet owner reported that the product was applied to his 3-year-old, 89 pound, male dog one day prior to initial contact with the registrant and ten to fifteen minutes after product application the dog started drooling and acting anxious. The dog still had symptoms at the time of initial contact. The reporter was advised that drooling may occur with ingestion of the product due to the unpleasant taste. Bathing with a non-insecticidal shampoo was recommended and the reporter was advised to seek veterinary care if symptoms persist. 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
Minor
19. Provide supplemental information here