Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-6755
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-42522799
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.
23-NOV-15
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
22-NOV-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. 2596-78
Product Name: UltraGuard Flea/Tick Powder for Cats
- 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?
Unknown
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
Male
6. Age (provide a range if necessary )
3
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
<=30 min / <=30 min
11. List all symptoms
System
- General
- Symptom - Death
- Symptom - Lethargy
- Symptom - Vocalizing
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
1-42522799 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal powder containing the active ingredient tetrachlorvinphos. The pet owner applied the product to her 3-year-old, male cat one day prior to initial contact with the registrant to treat an active flea infestation. The cat was fine until the day of initial contact when the pet owner noticed that the cat was vocalizing and lethargic and then about 10 minutes prior to her call the cat passed away. The reporter had also applied the product to her other cat and that cat did not have any symptoms from the exposure. 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 for the cats death. 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