Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-6220
2. Registrant Information.
Registrant Reference Number: ProPharma Group case:# 1-49635635
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.
07-SEP-17
5. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
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. 2596-140
Product Name: HARTZ ULTRA GUARD PLUS FLEA & TICK SPRAY FOR CATS
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .07 %
- TETRACHLORVINPHOS
- Guarantee/concentration 1.08 %
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 1021-1723-2596
Product Name: HARTZ ULTRAGUARD RID FLEA & TICK SHAMPOO FOR CATS
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .479 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .3 %
- PYRETHRINS
- Guarantee/concentration .15 %
7. b) Type of formulation.
Liquid
Other (specify)
shampoo
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
Mixed
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
1
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Shaking
- Specify - Shivering
12. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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
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
1-49635635 - The reporter, a pet owner, indicated her cat was exposed to insecticidal products containing the active ingredients tetrachlorvinphos, (S)-methoprene, pyrethrins, piperonyl butoxide, and N-octyl bicycloheptene dicarboximide. Approximately three weeks before the day of initial contact with the registrant, the reporter indicated she placed the products on her 1-year-old, mixed breed cat of unknown weight and gender. Twenty four hours later, the cat developed anorexia, pruritus, shivering, and peeling skin. The cat died one week before the day of initial contact with the registrant. 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