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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2993

2. Registrant Information.

Registrant Reference Number: 259229

Registrant Name (Full Legal Name no abbreviations): Hartz Canada, Inc.

Address: 1125 Talbot Street

City: St. Thomas

Prov / State: ON

Country: Canada

Postal Code: N5P 3W7

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

26-APR-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 26133      PMRA Submission No.       EPA Registration No.

Product Name: HARTZ ULTRAGUARD FLEA TICK SHAMPOO FOR DOGS

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN
    • PIPERONYL BUTOXIDE

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 )

1

7. Weight (provide a range if necessary )

18.5

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • Skin
    • Symptom - Itchy skin
  • Gastrointestinal System
    • Symptom - Bloody stool
    • Symptom - Bloody vomit
    • Symptom - Bloody diarrhea
  • General
    • Symptom - Biting
    • Specify - biting itself

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?

Yes

14. b) How long was the animal hospitalized?

24

Hour(s) / Heure(s)

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

April 24th bought shampoo and washed dog. Dog scratching. April 25 noticed yellow vomit. Continued scratching and biting body non-stop to point it started bleeding. Evening did not eat food. Called Hartz on April 26th, and advised dog had reaction to product, advised to give thorough bath with mild shampoo, towel dry and keep a close eye. Washed him. Dog did not eat. During night vomiting and diarrhea. On April 27th blood in vomit and stool. Dog taken to vet, where kept for 24 hours and diagnosed with hemorrhagic gastroenteritis put on IV and antibiotic. April 28th vet advised more vomit even without food, suggested X ray but negative results. In evening discharged with more medication.


To be determined by Registrant

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

Major

19. Provide supplemental information here