Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-1038
2. Registrant Information.
Registrant Reference Number: 090305-000032
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.
21-AUG-08
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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.
Product Name: Sergeants Pretect Household Flea Spray
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name:
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name:
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).
Used the drops on his cat and within a few hours started acting weird and having convulsions
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
Himalyan
4. Number of animals affected
2
5. Sex
Male
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
Unknown / Inconnu
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
Flea Spray purchased the flea spray approximately 8-9 months ago, used twice. The first time the product made them ill but not deathly ill. When used the past time one of his cats went into a frenzy and ran away. Didn¿t see this cat for 1 or 2 days. Reappeared on doorstep, she was weak on her feet and was almost lifeless. Quickly given water, seemed to be coming around however died later in the evening. Other cat also showed signs of sickness, died in the middle of the night.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
No medical attention, no autopsy.