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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-3990

2. Registrant Information.

Registrant Reference Number: Prosar 1-19528854

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.


5. Location of incident.


Prov / State: INDIANA

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-22

Product Name: UltraGuard Rid Flea/Tick Shampoo for Dogs Clean Fresh Scent 18 fl oz

  • Active Ingredient(s)
      • Guarantee/concentration .149 %
      • Guarantee/concentration .089 %
      • Guarantee/concentration .045 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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 to wash 2 dogs on 08/13/2009.

To be determined by Registrant

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


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Adipsia
  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

1-19528854: A reporter (dog owner) called on 08/14/2009 to report the exposure of his 2 dogs to a flea and tick shampoo containing the active ingredients Pyrethrins, Piperonyl Butoxide, and NOBD. According to the reporter, the product was used to bathe the dogs on 08/13/2009. Dog #1 (1st Subform III) ran off while the reporter was rinsing the other dog and could not be found for 45 minutes. Dog #1 began vomiting, not eating, and not drinking 6-7 hours later. The reporter bathed the dog twice in a non-insecticidal shampoo, but the signs were persistent at the time of the report. The reporter was advised that the product has a wide margin of safety and low level of toxicity when used as directed. Ingestion of small amounts of product from her coat may result in gastrointestinal signs such as nausea, vomiting, and diarrhea. A recommendation was made to replace fluids by offering Gatorade or Pedialyte. It was also recommended to have the dog evaluated by a veterinarian to determine the cause for the signs. The other dog was asymptomatic. On follow up, the reporter stated that Dog #1 drank some Gatorade on 08/14/2009 and then curled up in a ball. When the reporter checked on her 8-9 hours later, Dog #1 had died. The other dog remained asymptomatic. No further information was obtained.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here