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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2245

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25959803

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.

25-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

24-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. 2596-22

Product Name: UltraGuard Rid Flea Dog Shampoo Refreshing Fresh Citrus

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .149 %
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration .089 %
    • PYRETHRINS
      • Guarantee/concentration .045 %

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.125

7. Weight (provide a range if necessary )

3

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 - Unconsciousness
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

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

1-25959803- The reporter, a pet owner, indicated her animal had been exposed to an insecticidal product with the active ingredients Pyrethrins, Piperonyl butoxide, and N-octyl bicycloheptene dicarboximide. The pet owner indicates she applied the product, a flea and tick shampoo labeled for dogs twelve weeks and older, to her eight week three pound male Yorkshire terrier two days prior to her initial contact with the registrant. The pet owner indicated the day after application the pet was found unconscious on the floor. The pet was promptly brought to the veterinarian where attempts were made to revive it but the animal died. The pet owner was advised that the signs seen would not be expected despite the fact that the product is not labeled for animal less than twelve weeks of age. She, at this point, indicated the animal was four months of age. The animal¿s actual age is unknown. The pet owner was advised of registrant supported necropsy that may assist in determining the animal¿s cause of death. It is unknown if the caller followed through with the necropsy program. 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