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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4596

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-27148381

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.

15-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

12-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. 25923      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea Tick Drops for Dogs Puppies Under 30 lbs

  • Active Ingredient(s)
    • PERMETHRIN

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

Miniature Schnauzer

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

3.5

7. Weight (provide a range if necessary )

14

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Seizure
  • Skin
    • Symptom - Skin sensitivity
    • Specify - skin would wrinkle up

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

1-27148381- the reporter, a pet owner, indicated her animal had been exposed to an insecticidal product containing the active ingredient permethrin. The reporter indicated she had applied the product to her three and one half year male fourteen pound miniature schnauzer dog two weeks prior to her initial contact with the registrant. The pet owner stated her animals had a seizure of two minutes in length ten days after application. The pet had one additional seizure the following day that was shorter in duration. The reporter indicated she had not yet seen a veterinarian. The pet owner stated the previous time she had applied the product one month prior to her initial contact she had noted when she touched the application are the pets skin at the site of application would wrinkle up. The caller was advised to seek veterinary assistance as the symptoms and time line were inconsistent with use of the product according to the label. The pet owner was not reached for follow up. No additional 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