Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-7370
2. Registrant Information.
Registrant Reference Number: 161207-000068
Registrant Name (Full Legal Name no abbreviations): Rolf C Hagen Inc
Address: 20500 Trans Canada Hwy
City: Baie d'Urf
Prov / State: Qc
Country: Canada
Postal Code: H9X 0A2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
07-DEC-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
15-NOV-16
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. 21629
PMRA Submission No.
EPA Registration No.
Product Name: Sergeant's Flea & Tick Spray for Dogs
7. b) Type of formulation.
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).
The spray was appplied by starting from the tail base up to mid back/shoulder blades to treat an existing flea infestation.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
25
lbs
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
- Skin
- Symptom - Hair loss
- Symptom - Pruritus
- Symptom - Dry skin
- Symptom - Peeling skin
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Unknown/Inconnu
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
The day after the product was applied, the pet owner noticed bumps, flaking skin and hair loss on the pet's back, where the product was applied. The scratching increased. The pet was brought into a DMV on 11/15/2016 were it was diagnosed with a skin infection. The pet was prescribed antibiotics, medicated shampoo and Advantage II for flea treatment. The pet was rechecked on 11/29/2016 at the DVM. The skin was still peeling and the fur continued to fall.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here