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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2647

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26052411

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-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

30-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. 2596-150

Product Name: UltraGuard Plus Flea Tick Drops Plus for Dogs Puppies

  • Active Ingredient(s)
    • (S)-METHOPRENE
      • Guarantee/concentration 2.3 %
    • D-PHENOTHRIN
      • Guarantee/concentration 85.7 %

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

Dog / Chien

3. Breed

Shih Tzu

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

13

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

  • Nervous and Muscular Systems
    • Symptom - Muscle tremors
  • General
    • Symptom - Malaise
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • General
    • Symptom - Death
  • Renal System
    • Symptom - Other
    • Specify - urinary tract infection

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?

Unknown

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

1-26052411-The reporter, a pet owner, indicates her animal was exposed to a pesticide containing the active ingredient phenothrin and methoprene. The reporter indicated she had applied the product to her five year thirteen pound female Shih Tzu dog four days prior to the initial contact with the registrant. The animal was also administered a Heartguard heartworm preventative medication at the same time. The pet owner indicated the same day these two products were administered the animal developed tremors and malaise. Three days later the animal was brought to the veterinarian and diagnosed with a urinary tract infection. The animal was then placed on an oral antibiotic (not specified). Four days after application the animal developed seizures, was brought to the veterinarian, and died later that day. The pet owner was advised the signs seen would not be expected following use as labeled. She was advised of registrant supported necropsy and her veterinarian was supplied with submission forms. The pet owner spontaneously called back at a later date and indicted she had stored the animal¿s remains in the garage unrefrigerated. She asked if necropsy could still be done. The pet owner was advised that the animal¿s remains had likely undergone autolysis and tissue degradation sufficient to render necropsy no longer valuable. 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