Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2234
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-25790963
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.
05-APR-11
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
05-APR-11
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.
PMRA Submission No.
EPA Registration No. 2596-140
Product Name: UltraGuard Plus Flea Tick Spray for Cats
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration .07 %
- TETRACHLORVINPHOS
- Guarantee/concentration 1.08 %
7. b) Type of formulation.
Liquid
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 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
1
5. Sex
Male
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
- Nervous and Muscular Systems
- Eye
- Symptom - Other
- Specify - "staring blankly"
- Gastrointestinal System
- Symptom - Oral hemorrhage
- General
- Symptom - Vocalizing
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
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
Died
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
1-25790963- The reporter, a pet owner, calls to indicate exposure of his animal to a pesticide containing the active ingredients tetrachlorvinphos and methoprene. The pet owner indicated he had applied the product, a topical flea and tick preventative, to his nine year twelve pound male domestic shorthair cat the day prior to his initial contact with the registrant. The pet owner indicated he had awakened this morning to find his animal drooling vocalizing, staring blankly, developing convulsions, and bleeding from its oral cavity. He indicates the animal then died. He did not see a veterinarian and had buried the animal at the point of the call. The pet owner was advised the signs seen would be unexpected following the use of the product as labeled. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here