Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-3912
2. Registrant Information.
Registrant Reference Number: PROSAR Case #1-26785665
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.
11-JUL-11
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
11-JUL-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. 25923
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Flea Tick Drops for Dogs Puppies Under 30 lbs
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic shorthair
4. Number of animals affected
2
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
Oral
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 - Muscle tremors
- Symptom - Ataxia
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
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
1-26785665- The reporter, a pet owner indicates her two animals had been exposed to an insecticide containing the active ingredient permethrin. The pet owner indicated she knowingly used the canine flea and tick preventative against the label on her two female domestic shorthair cats the day prior to her initial contact. At the point of her initial contact she had noted the animals had developed muscle tremors and ataxia. She had bathed the animals. The pet owner was advised to seek immediate veterinary care for the animals. She was advised beyond bathing the animal care must be provided by a veterinarian. She was further advised to closely follow label instructions when using similar products going forward. The pet owner did not respond to follow up attempts. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here