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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2755

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.

Human

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

27-MAY-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. 29930      PMRA Submission No.       EPA Registration No.

Product Name: HARTZ ULTRAGUARD ONE SPOT DROPS FOR CATS AND KITTENS

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

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Units: mL

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).

1 stated dosaged as instructed by package between cats shoulder blades. 1ml tube. It was the first and only dosage. It was on my cat for less then 20 minutes before I was able to grab him to begin washing off. Symptoms occurred within less than 1 minute of application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Unknown

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • General
    • Symptom - Malaise
  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • Gastrointestinal System
    • Symptom - Nausea
    • Specify - queasy

4. How long did the symptoms last?

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

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

I also fell sick, queasy and dizzy for over 24 hours after trying to remove this product from my cat. I am (age) and healthy.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic

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?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Foaming at mouth
  • Respiratory System
    • Symptom - Wheezing
  • Nervous and Muscular Systems
    • Symptom - Agitation
    • Specify - frantic
    • Symptom - Other
    • Specify - involuntary jaw movements
  • Skin
    • Symptom - Itchy skin
  • General
    • Symptom - Vocalizing
    • Specify - hissing, crying
  • Skin
    • Symptom - Hair loss
    • Symptom - Other
    • Specify - baldness
  • General
    • Symptom - Abnormal behaviour
    • Specify - withdrawn behaviour, scared
  • Skin
    • Symptom - Dry skin
    • Specify - chronic dandruff

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Recvrd resid.effects/Rétabli séquelles

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

Immediately on the first application of the product the following occurred; extreme foaming at mouth,wheezing,frantic,involuntary jaw movements,scratching,hissing,crying. After the incident: hair loss,baldness where product was applied,chronic dandruff where product was applied, withdrawn behaviour and scared. Medical Treatment - Washed gently several times to try and remove product by myself.


To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here