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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2242

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25980008

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.

27-APR-11

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

25-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. 29283      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Pro Flea Tick Drops for Dogs Puppies

  • Active Ingredient(s)
    • (S)-METHOPRENE
    • PERMETHRIN

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

mixed breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

15.5

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Agitation
  • Skin
    • Symptom - Blister

12. How long did the symptoms last?

Unknown / Inconnu

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

Yes

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

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

1-25980008- The reporter, a pet owner, indicates her animal was exposed to an insecticidal product containing the active ingredients permethrin and methoprene. The pet owner stated she applied the product, a topical flea and tick drop, to her five year fifteen pound male mixed breed dog three days prior to her initial contact with the registrant. The day following application the pet owner indicated her animal developed agitation and she noted the area of application had developed blistered skin. The pet owner indicates she had shampooed the animal with a non-insecticidal shampoo within two hours of the initial contact. The pet owner was advised to seek veterinary occasional idiosyncratic dermal reactions to pyrethroids can take place in domestic animals. Care would be expected to be predominantly symptomatic following decontamination. The pet owner spontaneously called back later the same day and reported she had been to the veterinarian. The animal had blood work run, it was prescribed a topical cream (nonspecific), oral antibiotics and antihistamines. No further information is available.


To be determined by Registrant

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

Moderate

19. Provide supplemental information here