Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-1319
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-39859017
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.
05-MAR-15
5. Location of incident.
Country: UNITED STATES
Prov / State: ALABAMA
6. Date incident was first observed.
05-MAR-15
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. 2596-153
Product Name: UltraGuard Rid Flea Dog Shampoo Fresh Scent
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration .27 %
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
0.16
7. Weight (provide a range if necessary )
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
Unknown / Inconnu
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.
Yes
14. a) Was the animal hospitalized?
Unknown
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
1-39859017 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal dog shampoo containing the active ingredient phenothrin. The reporter bathed his 2-month-old dog with the product on the day of initial contact with the registrant. During the bath the dog did drink some of the bath water. The reporter also stated that one day prior to initial contact with the registrant the dog also ingested some mop water that contained bleach. After the bath the dog started having seizures. The reporter took his dog to the veterinarian where it subsequently died. The reporter was advised that per package labeling the shampoo is not meant to be used on dogs less than 6 months of age. The reporter was advised that there are numerous possible causes for the described symptoms and a necropsy was recommended to help determine an underlying cause. No additional 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