Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2679
2. Registrant Information.
Registrant Reference Number: Prosar 1-18308491
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.
01-MAY-09
5. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
6. Date incident was first observed.
24-APR-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. 2596-151
Product Name: UltraGuard Flea/Tick Drops for Dogs/Puppies 4-15 lbs
- 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).
The product was applied to the dog on 04/23/2009.
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Unknown breed
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
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.
Unknown
14. a) Was the animal hospitalized?
Unknown
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
1-18308491: A reporter (customer service representative) called on 05/01/2009 to report a call from a pet owner whose dog died following exposure to a flea and tick product containing the active ingredient Phenothrin. The owner had reported that the product had been applied to the dog on 04/23/2009. The dog died on 04/24/2009. Multiple attempts at follow up with the dog owner were unsuccessful, and no further information was obtained. It is unknown what signs the dog developed, when the signs began, and whether any veterinary evaluation or treatment was performed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here