Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5389
2. Registrant Information.
Registrant Reference Number: 1-24011475
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.
04-SEP-10
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
31-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. 26491
PMRA Submission No.
EPA Registration No.
Product Name: HARTZ ULTRAGUARD ONE SPOT TREATMENT FOR CATS KITTENS
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).
Caller applied the drops to her 4 cats on Tuesday, 8/31710. Those 3 three cats are asymptomatic. Caller's cat' [name] a female 8-9 yo 5# DSH cat is lethargic, had dilated eyes and is not eating. She noticed these symptoms yesterday and today. Calling back to say that she sent a lengthy email to the company regarding this and she doubts she will get a response. She says that about 30-45 minutes after speaking her cat died. She says the cat is in the freezer right now because she isn't sure if the company would want to test her or the product because someone could have tampered with it.
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
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
8.5
7. Weight (provide a range if necessary )
5
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Eye
- Symptom - Pupil dilation
- Specify - mydriasis
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
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