Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0750

2. Registrant Information.

Registrant Reference Number: 388191

Registrant Name (Full Legal Name no abbreviations): Sergeant's Pet Care Products Inc.

Address: 2625 South 158th Plaza

City: Omaha

Prov / State: NE

Country: USA

Postal Code: 68130

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

06-OCT-08

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

06-OCT-08

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2517-87

Product Name: Sergeant's Squeeze on for dogs and puppies

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration 45 %
  • PYRIPROXYFEN
    • Guarantee/concentration 1.9 %

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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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

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 )

1

7. Weight (provide a range if necessary )

58

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Seizure

• General
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Diarrhea

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

Caller put the product on her dog's yesterday around 11 pm and around 4 am they woke up and Ginger was seizing and Roxie had diarrhea. She called around and could not find a clinic that was open. She got a hold of someone who works for a DVM who said to bathe the dog with dish soap. She bathed the dog numerous times, but it passed away around 9 am.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here