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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-4590
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-27108262
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-AUG-115. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
6. Date incident was first observed.
Unknown
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. PMRA Submission No. EPA Registration No. 2596-22
Product Name: UltraGuard Rid Flea Tick Shampoo for Cats
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .149 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .089 %
- PYRETHRINS
- Guarantee/concentration .045 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
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?
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 cat
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
7
lbs
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 / <=30 min
11. List all symptoms
System
- General
- Symptom - Death
- Nervous and Muscular Systems
- Symptom - Collapse
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
1-27108262- The reporter, a pet owner, indicated her animal had been exposed to an insecticide containing the active ingredients pyrethrins, piperonyl butoxide, and n-octyl bicycloheptene dicarboximide. The reporter indicated she washed her seven year male seven pound domestic shorthair cat with the product. She did not provide a time frame when the animal was treated with the product. She indicated one week prior she had applied a topical flea and tick product to the animal as well. She was unable to give any identification information for the topical flea and tick product previously applied. The caller indicated the animal collapsed during the bathing and soon thereafter recovered. Later the same day the animal died. The pet was not brought to the veterinarian during the course of its health difficulty or after its death. The pet owner was advised the label discourages the use of multiple overlapping flea and tick medications. The registrants product indicated here would not be expected to elicit the signs seen or the out come seen and certainly not in the abrupt fashion seen. It is likely the pet had some other undiagnosed malady the lead to its collapse. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
