Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1824

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: QUEBEC

6. Date incident was first observed.

29-APR-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.

Product Name: Zodiac flea collar

• Active Ingredient(s)
  • (S)-METHOPRENE
  • PROPOXUR

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Zodiac flea shampoo

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Other Units: collar

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).

1 Flea collar applied as directed by product label. 1 flea collar of 10% propoxur (may include 2% methoprene), left on for - 2 - 4 days. Cat was also bathed with Zodiac flea shampoo (containing pyrethrins 0.05% and Piperonyl butoxide 0.5%) prior to placing flea collar. There is a patch of hair loss on the ventral abdomen that may have been present prior to treatment, but unknown. No obvious signs of toxicity from shampoo.

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 shorthair

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Skin
  • Symptom - Hair loss
  • Symptom - Blister
  • Symptom - Itchy skin
  • Symptom - Lesion
  • Specify - red sores, raw spots

12. How long did the symptoms last?

Unknown / Inconnu

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

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

Owners applied flea collar the week before presentation to clinic. They noticed raw spots, hair loss, and blisters under the collar a few days after application. They removed the collar - 5 days before presentation and have been washing the area with water. The sores progressed then started to improve the day before presentation. On presentation, there were patches of hair loss around neck at collar location, with multiple shallow, red sores. Neck was itchy and cat kept trying to scratch. Neck was shaved, and sores were cleaned with chlorexadine soap. Allowed to heal openly.

---

To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here