Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2921

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-22739906

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: TEXAS

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. 2596-153

Product Name: 2 in 1 Flea Tick Shampoo with Oatmeal for Dogs

  • Active Ingredient(s)
      • Guarantee/concentration .27 %

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).

product applied to a domestic animal (dog), no further information available

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

Medical Professional

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

Unknown / Inconnu

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy
    • 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

1-22739906 ¿ The reporter a, veterinary technician, calls to indicate a patient has been exposed an insecticide with the active ingredient D-Phenothrin. The caller reports she has received a call from the owner of a 3 pound12 week male Chihuahua dog that had the product applied 3 days before the first contact with the registrant. The owner had conveyed the animal had begun to spontaneously vomit immediately following application. The animal had continued to vomit until the point of the call (3 days) and had at that point developed lethargy as well. The caller was advised to rule out other potential etiologies, while they wash the animal in a non-insecticidal shampoo. The caller was told to offer the animal care to address signs as they present. On routine call back to the veterinary clinic it was revealed the owners did not seek veterinary care due to financial constraints. The veterinary clinic advised the use of over the counter wormers, oral electrolyte solutions, and high calorie nutritional supplements in the absence of veterinary care. The owner of the animal spontaneously called the registrant later the same day and advised the animal had died. The owner reported she had followed her veterinarian¿s instructions and the animal dies despite her efforts the evening of the initial call to the registrant. The animal had been buried and consequently necropsy could not be advised. The owner was advised the effect observed would be unexpected following routine use of the product as labeled. She was informed the animal may have had an underlying sensitivity or undiagnosed medical condition.

To be determined by Registrant

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


19. Provide supplemental information here