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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-3936
2. Registrant Information.
Registrant Reference Number: PROSAR Case #1-26964572
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.
27-JUL-115. Location of incident.
Country: UNITED STATES
Prov / State: INDIANA
6. Date incident was first observed.
19-JUL-11Product 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. 2596-124
Product Name: UltraGuard Flea Tick Conditioning Shampoo for Cats
- Active Ingredient(s)
- D-TRANS ALLETHRIN
- Guarantee/concentration .109 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .151 %
- D-TRANS ALLETHRIN
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
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
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
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
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
1-26964572- The reporter indicated exposure of pets to an insecticide containing the active ingredients allethrin and n-octyl bicycloheptene dicarboximide. The reporter indicated she was calling on behalf of her daughter who had treated her pets with the product eight days prior to her initial contact with the registrant. The reporter indicated her daughter had washed her two cats with the product, a flea shampoo labeled for use on cats. She indicated one cat, a seven year male (Subform III, #1) had passed away within minutes of using the product. She indicated the death occurs not more than one hour following use and it showed no signs preceding its death. The second animal, a female cat of seven years (Subform III, #2) was lethargic and weak following use and died the next day. A veterinarian was consulted at no time preceding death or following deaths. The caller was advised use of the product as labeled would not be expected to result in the signs seen nor the outcome. She was advised of registrant supported necropsy to assist in determining the animal¿s cause of death. 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
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7
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
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Muscle weakness
- General
- Symptom - Lethargy
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
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
1-26964572- The reporter indicated exposure of pets to an insecticide containing the active ingredients allethrin and n-octyl bicycloheptene dicarboximide. The reporter indicated she was calling on behalf of her daughter who had treated her pets with the product eight days prior to her initial contact with the registrant. The reporter indicated her daughter had washed her two cats with the product, a flea shampoo labeled for use on cats. She indicated one cat, a seven year male (Subform III, #1) had passed away within minutes of using the product. She indicated the death occurs not more than one hour following use and it showed no signs preceding its death. The second animal, a female cat of seven years (Subform III, #2) was lethargic and weak following use and died the next day. A veterinarian was consulted at no time preceding death or following deaths. The caller was advised use of the product as labeled would not be expected to result in the signs seen nor the outcome. She was advised of registrant supported necropsy to assist in determining the animal¿s cause of death. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
