Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-3266

2. Registrant Information.

Registrant Reference Number: 468865

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.

07-MAY-09

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

06-MAY-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 69332-3-2517

Product Name: Sergeant's Gold Squeeze on For Cats and Kittens

• Active Ingredient(s)
  • ETOFENPROX
    • Guarantee/concentration 55 %
  • PYRIPROXYFEN
    • Guarantee/concentration 2.2 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

1.4

Units: mL

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

9.5

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>8 hrs <= 24 hrs / >8 h <= 24 h

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Eye
  • Symptom - Pupil dilation

• Gastrointestinal System
  • Symptom - Drooling

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Shaking

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?

Unknown

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

Caller is a receptionist. She says that they have a cat presenting to them with a hx of having product applied to it about 24 hours ago. Owner went to work after applying it. Upon arrival home from work cat was found to be drooling, shaking, ataxic, and with dilated pupils. Caller is trying to relate information back and forth with me and DVM. Caller wondering if this inhibits acetyl cholinesterase. A: This is not known or expected to happen with normal use of product. This does not inhibit the acetyl cholinesterase. .Sounds potentially like pyrethrin toxicity. Recommend you see if animal does have a dog she treated at home with dog product Please have DVM call to discuss this case and possible therapies. Gave case# (Name) may 26, 2009 1:47PM Callback attempted. Receptionist states that the cat died but did not have additional information with her at this time. She states that the DVM managed the case as a pyrethrin toxicity but there is no evidence to support exposure to another product. Left case and phone number for CB with additional follow-up info.

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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