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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-6296

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24773935

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-NOV-10

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

19-NOV-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. 2596-84

Product Name: UltraGuard Flea Tick Collar for Puppies White

  • Active Ingredient(s)
    • TETRACHLORVINPHOS
      • Guarantee/concentration 14.55 %

7. b) Type of formulation.

Other (specify)

collar

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

Shih Tzu

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

15.5

lbs

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

  • Nervous and Muscular Systems
    • Symptom - Seizure
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Muscle twitching

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

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

1-24773935- The reporter, a veterinarian, indicates a patient of hers was exposed to a pesticide containing the active ingredient tetrachlorvinphos. The veterinarian indicated the pet¿s owner had applied the product, a flea and tick collar labeled for dogs, to their four year female fifteen pound Shih Tzu dog four days prior to the initial contact with the registrant. The pet owner had reported they had seen a seizure in the animal the day after application. The veterinarian stated the animal presented that afternoon (of the first seizure). Upon presentation the animal was observed to have focal seizures and twitching. The veterinarian reported the animals symptoms persisted despite treatment with anticonvulsants (nonspecific). She ran a full blood profile and indicated no abnormalities. The animal was referred to a local emergency clinic for care over the evening. The animal was reported to have died the next morning one day prior to the initial contact with the registrant. The veterinarian was advised the out come seen and symptoms seen were unexpected following use as labeled. The veterinarian was advised of a registrant supported necropsy program to assist in determining cause of death. No further information is available.


To be determined by Registrant

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

Death

19. Provide supplemental information here