Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-0792
2. Registrant Information.
Registrant Reference Number: 1-24644036
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.
08-NOV-10
5. Location of incident.
Country: CANADA
Prov / State: NEWFOUNDLAND
6. Date incident was first observed.
07-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. 26491
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard One Spot Treatment for Cats and 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).
Caller applied the drops to her 3 Purebread Persian cats yesterday and within 3 minutes she noticed that all of her cats at various times developed symptoms of vocalizing, agitated and their backs were itching.
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
Cat / Chat
3. Breed
Persian
4. Number of animals affected
3
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
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 / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
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
Fully Recovered / Complètement rétabli
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
Caller applied the drops to her 3 Persian Cats (caller would not give animal info when asked several times) yesterday for the first time and she noticed within 3 minutes of applying the drops to the cats all 3 of the cats at various times developed symptoms of vocalizing, agitated and their backs were itching. Caller did bathe the 3 cats with soap and water and symptoms disappeared.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here