Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-0092
2. Registrant Information.
Registrant Reference Number: 232686
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.
31-AUG-10
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
Unknown
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).
the consumer had given the cat a bath with Zodiac Flea Tick Cat Shampoo. After 1 hour, she applied the Ultra Guard One Spot for Cats. Approximately 15 minutes later, the cat was having a reaction and the consumer took the cat to the vet. the consumer no longer has the package any more and the rest of the vet information will be forwarded later.
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
Other
2. Type of animal affected
Cat / Chat
3. Breed
N/A
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
7
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Cardiovascular System
- Symptom - Abnormally fast heart rate
- Specify - high rhythm heart beat
- Respiratory System
- Symptom - Respiratory distress
- Specify - suffocating
12. How long did the symptoms last?
Unknown / Inconnu
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
Unknown/Inconnu
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
Moderate
19. Provide supplemental information here