Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-1577
2. Registrant Information.
Registrant Reference Number: Prosar 1-17815495
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.
12-MAR-09
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
09-MAR-09
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. 2596-22
Product Name: 2 in 1 Rid Flea Dog Shampoo 18 fl oz
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .149 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .089 %
- PYRETHRINS
- Guarantee/concentration .045 %
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).
The product was used on the dog on 03/09/2009. A non-company shampoo was also used on the dog about one hour later.
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
Pit Bull
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.83
7. Weight (provide a range if necessary )
60
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Skin
- Symptom - Itchy skin
- Symptom - Hair loss
- Symptom - Hair loss
- Specify - "Completely bald except for head."
- Symptom - Erythema
- Symptom - Irritated skin
- Respiratory System
- Symptom - Respiratory failure
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
1-17815495: A reporter called on 03/12/2009 to report the exposure of a dog to a flea and tick shampoo containing the active ingredients Pyrethrins, Piperonyl Butoxide, and NOBD. According to the reporter, the product had been used on the dog on 03/09/2009. Within one hour of product use, the dog became very pruritic and started losing hair. Immediately after noticing the dog's signs, the reporter bathed the dog in a non-medicated shampoo. The hair loss continued until the dog was bald except for his head. The hairless areas had also become red and irritated. The dog stopped eating on 03/11/2009. Toward the end of the report, the reporter indicated that the dog may not be breathing. The reporter also stated that an unknown flea and tick powder was used on the dog one month prior. The reporter was advised that the product has a wide margin of safety when used as directed. The reporter was also advised that bathing was appropriate once adverse signs were noted. The reporter was advised to seek immediate veterinary evaluation given the concern for respiratory failure. On follow up on 03/13/2009, the reporter stated that the dog had died on 03/12/2009. No further information was obtained.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here