Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2959

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26654788

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.


5. Location of incident.


Prov / State: NEW JERSEY

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-79

Product Name: UltraGuard Flea Tick Powder for Dogs

  • Active Ingredient(s)
      • Guarantee/concentration 3.3 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Anorexia
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up
  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy
    • Symptom - Hypothermia
  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
  • Renal System
    • Symptom - Urinary incontinence
  • Respiratory System
    • Symptom - Pulmonary edema
  • Cardiovascular System
    • Symptom - Bradycardia
  • Blood
    • Symptom - Anemia
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

1-26654788- The reporter, a pet owner, indicated his animal was exposed to an insecticide containing the active ingredient tetrachlorvinphos. The pet owner indicated he applied the product to his three year female six pound Pomeranian dog four days prior to his initial contact with the registrant. He indicated the day following application the animal was unable to walk, refused food, was vomiting and lethargic. The next day the animal demonstrated urinary incontinence, weakness and a slow heart rate. The animal was then brought to a veterinarian. The veterinarian¿s findings included hypothermia, anemia, pulmonary edema, and bradycardia. The animal was given intravenous fluids and an oral nutritional paste and discharged. The pet owner indicated the animal had no blood work drawn because the veterinarian had indicated the animal was too anemic to withstand the blood loss. The pet owner indicates the animal had a seizure at home two days following the application and died. The animal had been buried at the time of his initial contact. The pet owner was advised the signs seen, the veterinarian¿s findings and the out come would be unexpected following use of the product according to the label instructions. No further information is available.

To be determined by Registrant

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


19. Provide supplemental information here