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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1173

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25257910

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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. 2596-151

Product Name: Advanced Care 3 in 1 Once A Month Flea Tick Drops for Dogs

  • Active Ingredient(s)

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 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.


  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Insomnia
    • Specify - difficulty sleeping
  • Respiratory System
    • Symptom - Runny nose
    • Symptom - Nose bleed
    • Specify - bloody nasal discharge

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

1-25257910-The reporter indicates exposure to an insecticide containing the active ingredient phenothrin. The reporter indicates he had applied the product to his dog two days prior to the initial contact with the registrant. The reporter indicated the aroma of the product disagreed with him. He found the aroma so disagreeable he had to force his dog outside. He indicated he had also gotten the product on his hands, clothing and furniture. He reported he instantly noted nasal discharge/drainage and sleeplessness following application. The caller was advised of proper decontamination of the animal and himself. He was also advised how to clean the home/clothing. The caller was advised no harm would be expected following exposure to this aroma. He may have a unique sensitivity. On routine follow up the pet owner indicated he had not cleaned the animal to remove the aroma. He had allowed the animal back into the home. He stated he had a sinus headache for and nasal drainage for five days following application. He also indicated he had bloody discharge on his handkerchief when he blew his nose the day of follow up, but was unsure if that was related to the exposure. He indicated his symptoms were resolving spontaneously as the product aroma dissipated. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.