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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4705

2. Registrant Information.

Registrant Reference Number: Prosar 1-20124721

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.

22-SEP-09

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

21-SEP-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. 2496-149

Product Name: UltraGuard Plus Flea/TIck Dog Shampoo with Aloe

  • Active Ingredient(s)
    • (S)-METHOPRENE
      • Guarantee/concentration .101 %
    • D-TRANS ALLETHRIN
      • Guarantee/concentration .109 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .154 %

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 used to bathe a 15 year old dog on 09/21/2009. NOTE: This product is not labeled for use on aged dogs (defined by the company as dogs older than 10 years of age).

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

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

15

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • General
    • 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

1-20124721: A reporter (dog owner) called on 09/22/2009 to report the exposure of his dog to a flea and tick shampoo containing the active ingredients d-trans-Allethrin, Methoprene, and NOBD. According to the reporter, the product was used to bathe the dog on 09/21/2009 to treat a flea infestation. The reporter stated that he had rinsed the dog off and was drying him when the dog died. The reporter was advised that the product is not expected to result in adverse effects with routine use. The reporter was also advised that the product is not labeled for aged pets. No further information was obtained. NOTE: This product is not labeled for use on aged pets (defined by the company as dogs older than 10 years of age).


To be determined by Registrant

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

Death

19. Provide supplemental information here