Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5490
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-24021342
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.
06-SEP-10
5. Location of incident.
Country: UNITED STATES
Prov / State: VIRGINIA
6. Date incident was first observed.
03-SEP-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.
PMRA Submission No.
EPA Registration No. 2596-149
Product Name: UltraGuard Plus Flea TIck Dog Shampoo with Aloe
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .101 %
- D-TRANS ALLETHRIN
- Guarantee/concentration .109 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .154 %
7. b) Type of formulation.
Liquid
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
Labrador Retriever
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Difficulty getting up
- 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.
No
14. a) Was the animal hospitalized?
No
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
1-24021342- The reporter, a pet owner, indicates her animals have been exposed to an insecticide containing the active ingredients d-trans Allethrin, N-octyl bicycloheptene dicarboximide, and methoprene. The pet owner indicates she bathed both of her dogs with the product, a flea and tick shampoo, three days prior to the initial contact with the registrant. She noted her six month female Labrador Retriever began vomiting with two hours of use of the product. The animal then refused food, became lethargic, and would not rise. The caller stated the animal died the night prior to the initial contact with the registrant. The second animal bathed remained asymptomatic. She did not seek veterinary assistance during the animal¿s illness. The animal was buried before a necropsy could be performed. The reporter was advised this is unexpected to be related to the use of the product according to the label. The product contains low concentrations of well tolerated active ingredients. The animal was likely suffering from some unrelated undiagnosed condition.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here