Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-5128
2. Registrant Information.
Registrant Reference Number: 533885
Registrant Name (Full Legal Name no abbreviations): Sergeant's Pet Care Products, Inc. /DBA PetLogic, LLC
Address: 2625 South 158th Plaza
City: Omaha
Prov / State: NE
Country: United States
Postal Code: 68130
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
15-SEP-09
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
14-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. 69332-3-2517
Product Name: Sergeant's Gold Flea and Tick Squeeze-On for Cats and Kittens
- Active Ingredient(s)
- ETOFENPROX
- Guarantee/concentration 55 %
- PYRIPROXYFEN
- Guarantee/concentration 2.2 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
.7
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
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Skin
Unknown
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
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
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here