Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-4583
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-27026151
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.
02-AUG-11
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
02-AUG-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. 26491
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard One Spot Treatment for Cats Kittens
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
1
5. Sex
Male
6. Age (provide a range if necessary )
0.33
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
<=30 min / <=30 min
11. List all symptoms
System
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
1-27026151- The reporter, a pet owner, indicates her animal had been exposed to an insecticide containing the active ingredient methoprene. The pet owner indicated she had applied the product to her four month domestic short hair cat earlier that day. She indicated she had placed the product on a location on the animal where it may groom it from its coat. She had observed this take place earlier that day. The pet was observed lethargic and scratching at the application site at the point of the initial contact with the registrant. The pet owner was advised to wash the animal with a non insecticidal shampoo due to the improper placement of the product and seek veterinary assistance if symptoms persist or worsen. 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
Minor
19. Provide supplemental information here