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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1032

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-25016981

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.


5. Location of incident.


Prov / State: ILLINOIS

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-86

Product Name: UltraGuard Flea Tick Dip for Dogs Cats Concentrate

  • Active Ingredient(s)
      • Guarantee/concentration 1.11 %
      • Guarantee/concentration .67 %
      • Guarantee/concentration .33 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic shorthair

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Oral hemorrhage
    • Symptom - Rectal hemorrhage
    • Symptom - Anorexia
    • Symptom - Weight loss
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

1-25016981- The reporter, a pet owner, indicates his animal was exposed to an insecticide containing the active ingredients pyrethrins, piperonyl butoxide, and n-octyl bicycloheptene dicarboximide. The pet owner indicated he had applied the product, a topical flea and tick dip, to his eight year ten pound domestic shorthair cat four days prior to his initial contact with the registrant. The pet owner indicated when he had treated the animal with the product its flea infestation was severe enough that the water used to bathe the animal with became bloody. Some time after bathing the animal the pet owner indicated it began to lose weight. The pet owner indicated the day prior to his initial contact when he picked the animal up he noted oral and rectal hemorrhage. No veterinary assistance was sought and the animal died yesterday. The pet owner was advised the signs seen were inconsistent with the toxicity profile of the product even if an inappropriate exposure had occurred. The pet owner was quizzed about other potential exposures, such as anticoagulant rodenticides. The pet owner was advised of registrant supported necropsy to determine cause of death.

To be determined by Registrant

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


19. Provide supplemental information here