Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4971
2. Registrant Information.
Registrant Reference Number: PROSAR Case #:1-23676366
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.
03-AUG-10
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
Unknown
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. 26489
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Plus Flea TIck Drops for Dogs Puppies
- Active Ingredient(s)
- (S)-METHOPRENE
- PERMETHRIN
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
Dog / Chien
3. Breed
Beagle
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
20
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Skin
- Symptom - Pruritus
- Symptom - Erythema
12. How long did the symptoms last?
Unknown / Inconnu
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
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
1-23676366- The reporter, a pet owner, indicates her animal has been exposed to an insecticide containing the active ingredients permethrin and methoprene. The caller indicates she applied the product, a topical flea and tick drop to her one year female twenty pound beagle dog two weeks prior to her initial contact with the registrant. The caller indicates she used the product due to pre-existing itch and she felt the product only made the itch worse. The caller was informed the symptoms described would not be expected following routine use according to the label. The animal may have a previously unknown hypersensitivity or undiagnosed condition leading to its pruritis. The product is not labeled as an anti-pruruitic but as a treatment for ecto-parasites. It was advised that the animal be washed with a non-insecticidal shampoo and brought to the veterinarian if the signs persisted or worsened.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here