Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-3330
2. Registrant Information.
Registrant Reference Number: ProPharma Group case:# 1-48566685
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.
12-JUN-17
5. Location of incident.
Country: UNITED STATES
Prov / State: OKLAHOMA
6. Date incident was first observed.
Unknown
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. 2596-139
Product Name: HARTZ ULTRAGUARD PLUS FLEA&TICK COLLAR FOR DOGS
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration 1.02 %
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
7. b) Type of formulation.
Other (specify)
collar
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
Dog / Chien
3. Breed
Dachshund
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
11
7. Weight (provide a range if necessary )
12
lbs
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
- Nervous and Muscular Systems
- Symptom - Difficulty walking
- General
- Symptom - Death
- Symptom - Other
- Specify - Organ failure
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
1-48566685 - The reporter, a pet owner, indicated his dog was exposed to an insecticidal collar containing the active ingredients (S)-methoprene and tetrachlorvinphos. An unknown amount of time before the day of initial contact with the registrant, the reporter indicated she applied the collar to her 11-year-old, 12-pound, female Dachshund dog. Approximately one month before the day of initial contact, the dog developed lethargy, anorexia, and difficulty walking. Twenty-eight days before the day of initial contact, the dog was presented to a veterinarian who treated the dog with an antibiotic. The dog died on an unknown day of organ failure. No follow-up was done. 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