Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-6235
2. Registrant Information.
Registrant Reference Number: ProPharma Group case:# 1-49902926
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.
30-SEP-17
5. Location of incident.
Country: UNITED STATES
Prov / State: MICHIGAN
6. Date incident was first observed.
30-SEP-17
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. 2596-153
Product Name: HARTZ ULTRAGUARD RID FLEA & TICK SHAMPOO FOR DOGS WITH OATMEAL
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration .27 %
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).
1-49902926 - The product is intended for use on dogs only.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
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 )
Unknown
7. Weight (provide a range if necessary )
13
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
- Respiratory System
- Symptom - Shortness of breath
12. How long did the symptoms last?
Persisted until death
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
1-49902926 - The reporter, a pet owner, indicates his cat was exposed to an insecticidal shampoo containing the active ingredient D-phenothrin. On the day of initial contact with the registrant, the reporter stated he applied the product to his 13-pound, male cat of unknown age and breed, and within a few minutes the cat was short of breath and lethargic. The reporter was advised that the product is intended for use on dogs only, and he should immediately bathe the cat with a non-insecticidal shampoo, then bring the cat to a veterinarian for evaluation. The reporter called back approximately one hour after the time of initial contact to say that the cat had died. The reporter was not interested in a necropsy for the cat. 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