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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-6002

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24110827

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.

15-SEP-10

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

15-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. 2596-22

Product Name: UltraGuard Rid Flea Tick Shampoo for Dogs Clean Fresh Scent

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .149 %
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration .089 %
    • PYRETHRINS
      • Guarantee/concentration .045 %

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Golden retiever

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

11

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

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • General
    • 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

1-24110827- The reporter, a pet owner, states her animal has been exposed to an insecticide containing the active ingredients pyrethrins, piperonyl butoxide, and N-octyl bicycloheptene dicarboximide. The caller reports she used the product, a flea and tick shampoo labeled for use on dogs, on her eleven year male Golden retriever one day prior to the initial contact with the registrant. The caller stated her animal suddenly ┐┐┐dropped dead? ten hours following use of the product. She attributed the sudden death initially to a ┐┐┐heart attack?. The animal┐┐┐s remains were at the veterinarian┐┐┐s office at the time of the initial contact with the registrant waiting to be cremated. The caller was advised the product is not labeled for use on animal over ten years of age. Regardless, the result would not be expected to be related to the use of the product. The caller was advised a necropsy would be the best tool at this point to determine the animal┐┐┐s cause of death.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here