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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4049

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

15-JUL-13

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. 25923      PMRA Submission No.       EPA Registration No.

Product Name: Hartz ultraguard under 30lbs for dogs and puppies

  • Active Ingredient(s)
    • PERMETHRIN

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Units: mL

Other Units: tube

10. Site pesticide was applied to (select all that apply).

Site: Animal / Usage sur un animal domestique

Préciser le type: between the shoulder blades onto the skin

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

1 ml tube was applied to the back of the neck between the shoulder blades onto the skin. Spot-on treatment for dogs applied to the 5m kitten. 5-7lbs.

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

Cat / Chat

3. Breed

Domestic Short Hair

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

0.42

7. Weight (provide a range if necessary )

6

lbs

Unknown

8. Route(s) of exposure

Skin

Oral

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
    • Symptom - Seizure
    • Symptom - Muscle tremors

12. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Fully Recovered / Complètement rétabli

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

Application was given in the morning of 2013-07-15 seizuring and tremors occurred straight after the application and throughout until late afternoon on 16th July 13 phenobarbital 120mg/ml injection + Diazepam 5mg//ml injection given methocarbomol injection as needed. The cat had veterinary treatment roughly a couple of hours after symptoms seen. The kitten was given the flea/tick treatment (spot-on treatment) topical onto the skin. Possibly ingested topical treatment by licking at the site where applied. The 1ml tube was applied to the skin. Symptoms appeared immediately.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here