Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4990
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-23878423
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-AUG-10
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
22-AUG-10
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. 25922
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Flea TIck Drops for Dogs Puppies Over 30 lbs
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
domestic longhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
6
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Eye
- Symptom - Nystagmus
- Symptom - Pupil dilation
- Gastrointestinal System
- Symptom - Salivating excessively
12. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
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
Fully Recovered / Complètement rétabli
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
1-23878423- The reporter, a pet owner, indicates her animal was exposed to an insecticide containing the active ingredient permethrin. The caller indicates she had applied the product, a topical flea and tick drop labeled only for use on dogs, inadvertently to her five year six pound female domestic longhair cat 5-6 hours preceding the initial contact with the registrant. The animal had developed the signs of vomiting, tremor, nystagmus, mydriasis, and salivation within one hour of application. The pet owner had washed the animal but the signs had persisted. The pet owner was advised the decontamination described was appropriate. She was advised to seek veterinary assistance for further supportive care. On routine follow-up the reporter informed the registrant that the signs seen had resolved by the next morning. The animal was not brought to the veterinarian.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here