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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-1041
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-24939552
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.
Human
Domestic Animal
4. Date registrant was first informed of the incident.
11-DEC-105. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
11-DEC-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. 25620 PMRA Submission No. EPA Registration No.
Product Name: UltraGuard Flea Tick Collar for Dogs
- Active Ingredient(s)
- TETRACHLORVINPHOS
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).
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
- Gastrointestinal System
- Symptom - Stomach pain
- Respiratory System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>3 days <=1 wk / >3 jours <=1 sem
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.)
1-24939552- The reporter, a pet owner, indicates he and his animal were exposed to a pesticide containing the active ingredient tetrachlorvinphos. The pet owner stated he applied the product, a flea and tick collar, to his eight week twenty pound golden retriever three days prior to his initial contact with the registrant. The pet owner stated the animal demonstrated the signs loss of appetite, vomiting and was lying on her side shaking the day of initial contact. The pet owner also indicated he had touched the collar the day of application and had smoked a cigarette soon thereafter. He, the day of initial contact, had developed the symptoms of abdominal pain, and throat irritation. The pet owner was advised the exposure both to himself and his pet would not be expected to elicit the symptoms seen. He was advised to remove the collar from his pet and seek immediate veterinary care. He was likewise advised to seek a medical assessment for himself. On routine follow up a female in the home stated the animal was improved, it was not brought to the veterinarian. She refused to provide further information citing a shortage on her cellular phone minutes. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
golden retiever
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.15
7. Weight (provide a range if necessary )
20
lbs
8. Route(s) of exposure
Skin
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
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- Nervous and Muscular Systems
- Symptom - Recumbent
- Symptom - Shaking
12. How long did the symptoms last?
Unknown / Inconnu
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
1-24939552- The reporter, a pet owner, indicates he and his animal were exposed to a pesticide containing the active ingredient tetrachlorvinphos. The pet owner stated he applied the product, a flea and tick collar, to his eight week twenty pound golden retriever three days prior to his initial contact with the registrant. The pet owner stated the animal demonstrated the signs loss of appetite, vomiting and was lying on her side shaking the day of initial contact. The pet owner also indicated he had touched the collar the day of application and had smoked a cigarette soon thereafter. He, the day of initial contact, had developed the symptoms of abdominal pain, and throat irritation. The pet owner was advised the exposure both to himself and his pet would not be expected to elicit the symptoms seen. He was advised to remove the collar from his pet and seek immediate veterinary care. He was likewise advised to seek a medical assessment for himself. On routine follow up a female in the home stated the animal was improved, it was not brought to the veterinarian. She refused to provide further information citing a shortage on her cellular phone minutes. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
