Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-1583
2. Registrant Information.
Registrant Reference Number: Prosar case 1-15946228
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-08
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
24-FEB-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 2596-151
Product Name: Advanced Care 3 in 1 Once a Month Flea and Tick Drops for Dogs
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration 85.7 %
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
Chihuahua/Terrier Mix
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
13
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
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Bloody vomit
- Blood
- Symptom - Blood urea nitrogen increased
- Specify - Increased BUN
- Symptom - Blood urea nitrogen increased
- Specify - Increased Creatinine
- Symptom - Hypokalemia
- Blood
- Symptom - Thrombocytopenia
12. How long did the symptoms last?
Persisted until death
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?
3
Day(s) / Jour(s)
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
1-15946228: The reporter alerted the registrant by mail that her 3 year old dog had been exposed to a product containing Phenothrin on 2/23/08 and within 24 hrs. had become lethargic and anorexic, with episodes of hematemesis. The reporter stated she took the dog to a veterinarian for evaluation on 2/25/08. Blood tests were run including a Parvovirus test, and the dog was diagnosed with renal failure. Elevations in BUN and Creatinine, a depressed Potassium level, and Thrombocytopenia were among the most significant laboratory findings. Treatment was given including IV Fluids, IV antibiotics, Potassium supplementation, anti-emetics, and vitamin B12. The dog passed away in hospital on 2/28/08.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here