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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-6272

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24315383

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.

07-OCT-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

06-OCT-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. 2596-78

Product Name: UltraGuard Flea Tick Powder for Cats

  • Active Ingredient(s)
    • TETRACHLORVINPHOS
      • Guarantee/concentration 3.3 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Flea and Tick Shampoo (nonspecific)

  • Active Ingredient(s)
    • PERMETHRIN
      • Unknown

7. b) Type of formulation.

Liquid

Dust

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

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

13

7. Weight (provide a range if necessary )

11

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up
  • 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

1-24315383- The reporter, a pet owner, indicates her animal was exposed to insecticides containing the active ingredients tetrachlorvinphos and permethrin. The pet owner indicates she applied the registrant┐s product, a flea and tick powder containing the active ingredient tetrachlorvinphos, to her thirteen year eleven pound male cat three days prior to the initial contact with the registrant. The reporter indicates she had bathed her animal in an unknown insecticidal shampoo containing the active ingredient permethrin the day prior to the initial contact with the registrant. The pet owner indicates the animal collapsed and was unable to rise during the bath mentioned. The animal was reported to regain its strength following the bath but the collapsed one hour later and died. The animal was not brought to the veterinarian at any point in its illness, no necropsy was performed, and the animal was buried at the point of the initial contact with the registrant. No further information is available. The signs described would be unexpected following the use of the registrant┐s product according to the label. The use of the registrant┐s product is not recommended in animals above ten years of age and it is typically not recommended that multiple overlapping products of this nature be used.


To be determined by Registrant

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

Death

19. Provide supplemental information here