Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-1765
2. Registrant Information.
Registrant Reference Number: Prosar case 1-15731444
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.
28-JAN-08
5. Location of incident.
Country: UNITED STATES
Prov / State: TENNESSEE
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. 2596-149
Product Name: Advanced Care 3 in 1 Foaming Shampoo
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .1 %
- D-CIS, TRANS ALLETHRIN
- Guarantee/concentration .109 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .151 %
7. b) Type of formulation.
Liquid
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?
Yes
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 )
6
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
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
Case 1-15731444: The reporter called on 1/28/08 to report she had bathed her 3 year old male cat with a product containing the active ingredients 1) (S)-Methoprene, 2) D-CIS,Trans Allethrin, and 3) N-Octyl Bicycloheptene Dicarboximide. The reporter did not specify the date when the product was applied. According to the reporter, the cat then died on either 1/25/08 or 1/26/08. The reporter never took the cat to a veterinarian. Contact with the caller was lost in the middle of the phone call. A follow-up call was placed that same day to try and gather additional details. A voice mail was left but no response was ever received.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here