Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-5573
2. Registrant Information.
Registrant Reference Number: 1-34906641
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.
11-SEP-13
5. Location of incident.
Country: UNITED STATES
Prov / State: KENTUCKY
6. Date incident was first observed.
10-SEP-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.
PMRA Submission No.
EPA Registration No. 2596-79
Product Name: UltraGuard Flea/Tick Powder for Dogs
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 3.3 %
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Pit Bull Terrier
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
0.1875
7. Weight (provide a range if necessary )
Unknown
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
- Nervous and Muscular Systems
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?
No
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
1-34906641 - The reporter, a pet owner, indicated that his dogs were exposed to an insecticidal powder containing the active ingredient tetrachlorvinphos. The reporter applied the product to his three 9 week old pit bull puppies one day prior to initial contact with the registrant and the following day one of the puppies was foaming at the mouth and falling over (Subform III #1). The other 2 puppies never developed symptoms from the exposure. The reporter was advised that per package labeling the product is not meant to be applied to dogs less than 12 weeks of age. Immediate veterinary care was recommended for the symptomatic puppy and bathing was recommended for the two asymptomatic puppies. On follow up call, five days later, the reporter indicated that the puppy with symptoms passed away on the same day that he initially called. He never sought veterinary care for the animal. 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