Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-3125

2. Registrant Information.

Registrant Reference Number: 090819-000084

Registrant Name (Full Legal Name no abbreviations): Rolf C. Hagen Inc.

Address: 20500 Trans Canada Highway

City: Baie d'Urfe

Prov / State: Quebec

Country: Canada

Postal Code: H9X0A2

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

Domestic Animal

4. Date registrant was first informed of the incident.

19-AUG-09

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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)

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PMRA Registration No. 27667      PMRA Submission No.       EPA Registration No.

Product Name: Sergeant's Flea Collar for Cats

• Active Ingredient(s)
  • PROPOXUR

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Other Units: collar

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 collar was applied on an 8 week old kitten, though the packaging states that it should only be used on kittens over 12 weeks old. Furthermore, it was applied for prevention reasons, since the kitten itself did not have fleas, but was in contact with 4 adult cats that did have fleas.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.15

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Bloating

• General
  • Symptom - Loss of balance
  • Symptom - Weakness
  • Symptom - Death

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

Although the kitten did not have any fleas, the owner put a flea collar on him for prevention (she wanted to avoid him catching fleas from the other 4 adult cats in the house). One week after the application of the flea collar, cat started to have diarrhea, was bloated, had loss of balance and was weak. Kitten died on August 19th, 2009.

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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

The packaging for the flea collar states that it should only be used on kittens at least 12 weeks old. In this case, the cat was only 8 weeks of age.