Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2948
2. Registrant Information.
Registrant Reference Number: PROSAR cases: 1-26492496
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.
14-JUN-11
5. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
6. Date incident was first observed.
14-JUN-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
Lhasa Apso
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
Unknown
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
- Gastrointestinal System
- Symptom - Fecal incontinence
- Renal System
- Symptom - Inappropriate urination
- 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.
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
1-26492496- The reporter, a pet owner, indicated her animal was exposed to an insecticidal product containing the active ingredients phenothrin and methoprene. The pet owner indicated she applied the product to year female Lhasa apso dog the day prior to her initial contact with the registrant. The pet owner indicated she sis not know the weight of the animal but suspected it was less tan 15 pounds (the product is labeled for animal 4-15 pounds). The pet owner indicated the morning of her initial contact the animal had started whining, shaking and vomiting. The pet owner was advised symptoms of this nature following the use of the product according to the label would not be expected. She was advised to wash the animal in a noninsecticidal shampoo and seek immediate veterinary care. On follow up the pet owner indicated she had taken her animal to the veterinarian following her initial contact the animal was given a bath and a steroid shot. The animal died the next day. No further information was provided.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here