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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4166
2. Registrant Information.
Registrant Reference Number: 207264
Registrant Name (Full Legal Name no abbreviations): Hartz Canada, Inc.
Address: 1125 Talbot Street
City: St. Thomas
Prov / State: ON
Country: Canada
Postal Code: N5P 3W7
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
02-APR-105. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
30-MAR-10Product 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. 26491 PMRA Submission No. EPA Registration No.
Product Name: HARTZ ULTRAGUARD ONE SPOT TREATMENT FOR CATS KITTENS
- Active Ingredient(s)
- (S)-METHOPRENE
7. b) Type of formulation.
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
N/A
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
14.5
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Skin
- Symptom - Hair loss
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
Reason for Contact: I have been using this product for flea control on my cat for close to a year now once a month. He has always reacted as if he was crazy afterward for approximately 6 hours but I figured he was just angry at me for putting something wet on him although I did question whether it was a reaction to it or not. This month I put it on him as usual and he has started to lose his fur in a large patch on his side. After reading on-line about quite a few bad reactions animals have had to this medication I would like to get my money back from your company. I still have two tubes left in my package but will NOT be using them on my animal for fear of a worse reaction.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
