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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-0824
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-22536520
Registrant Name (Full Legal Name no abbreviations): The Hartz Mountain Corporation
Address: 400 Plaza Drive
City: Secaucus
Prov / State: NJ
Country: USA
Postal Code: 07094-3688
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
07-MAY-105. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
04-MAY-10Product 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. Unknown
Product Name: UltraGuard Reflective Flea Tick Collar for Dogs Puppies
- Active Ingredient(s)
- TETRACHLORVINPHOS
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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 II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Swollen eye
- Skin
- Symptom - Edema
- Symptom - Rash
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
Amount of time between application and contact 1
Day(s) / Jour(s)
What was the activity? Animal to which the collar was applied was sleeping with caller
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
1-22536520: The caller reports on 05/07/10 that he (sub form II #1) and his wife (sub form II #2) was exposed to a pesticide containing the AI tetrachlorvinphos. He reports he placed the product (a collar) on his dog 05/02/10. The dog was reported to have jumped into bed with the couple the morning of 05/03/10. The caller reports both he and his wife came in contact with the collar but did not specify by what avenue or the duration. The caller reports both he and his wife developed swollen eyes 05/04/10. On 05/05/10 the caller¿¿¿s right arms was reported to be swollen with a rash and his wife experienced swelling behind her ear. The caller reports the collar was removed the evening of 05/05/10 and at the time of the call he reports both people¿¿¿s symptoms were ¿¿¿greatly improved?. The caller was informed this is not an expected reaction with regular use of the product the affected individuals may have an unrecognized sensitivity to one of the ingredients.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Edema
- Eye
- Symptom - Swollen eye
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
Amount of time between application and contact 1
Day(s) / Jour(s)
What was the activity? Animal to which the collar was applied was sleeping with caller
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
1-22536520: The caller reports on 05/07/10 that he (sub form II #1) and his wife (sub form II #2) was exposed to a pesticide containing the AI tetrachlorvinphos. He reports he placed the product (a collar) on his dog 05/02/10. The dog was reported to have jumped into bed with the couple the morning of 05/03/10. The caller reports both he and his wife came in contact with the collar but did not specify by what avenue or the duration. The caller reports both he and his wife developed swollen eyes 05/04/10. On 05/05/10 the caller¿¿¿s right arms was reported to be swollen with a rash and his wife experienced swelling behind her ear. The caller reports the collar was removed the evening of 05/05/10 and at the time of the call he reports both people¿¿¿s symptoms were ¿¿¿greatly improved?. The caller was informed this is not an expected reaction with regular use of the product the affected individuals may have an unrecognized sensitivity to one of the ingredients.
To be determined by Registrant
14. Severity classification.
Minor
