Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4289
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-38187759
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.
20-AUG-14
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
16-AUG-14
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. 2596-22
Product Name: Ultraguard Rid Flea/Tick Shampoo for Cats
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .149 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .089 %
- PYRETHRINS
- Guarantee/concentration .045 %
7. b) Type of formulation.
Liquid
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
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
8
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
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
- 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
1-38187759 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal shampoo containing the active ingredients pyrethrins, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The reporter stated that she shampooed her 8-year-old, female cat with the product four days prior to initial contact with the registrant and then against labeled directions she re-bathed the cat three days prior to initial contact (labeling indicates that bathing may be repeated weekly). During the second bath the cat began to moan, it foamed at the mouth and had a seizure. Per the reporter the cat died within 10 minutes of product application. The reporter also indicated that it was possible that the cat may have ingested some of the shampoo. The reporter was advised that the product contains a very low concentration of active ingredients and the described symptoms are not consistent with use of the product. A necropsy could help determine an underlying cause for death but the reporter indicated that the body was no longer available. 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