Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5252

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-27438968

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.

Human

Domestic Animal

4. Date registrant was first informed of the incident.

15-SEP-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

15-SEP-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)

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PMRA Registration No. 26491      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard One Spot Treatment for Cats Kittens

• Active Ingredient(s)
  • (S)-METHOPRENE

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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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-27438968- The reporter, a pet owner, indicated she and her animals were exposed to and insecticidal product containing the active ingredient methoprene. The pet owner indicated she had applied the product to her five month kittens earlier the day of her initial contact. She reported she had observed one animal (Subform III, #1) groom or lick the product from its coat and had vomited. Another animal (Subform III, #2) had been observed to be lethargic. The reporter had also indicated she had some irritation to her finger following application. The reporter was advised of proper decontamination for all parties and supportive/symptomatic care that may be offered. On follow up the pet owner described her symptoms resolving by the end of the same evening she had contacted the registrant. She had bathed the animals with a hand dishwashing liquid and on had spontaneously resolved with two hours (Subform III, #1) the other she did not comment on. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. 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

Unknown

6. Age (provide a range if necessary )

0.41

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

• Gastrointestinal System
  • Symptom - Vomiting

12. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

Fully Recovered / Complètement rétabli

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

1-27438968- The reporter, a pet owner, indicated she and her animals were exposed to and insecticidal product containing the active ingredient methoprene. The pet owner indicated she had applied the product to her five month kittens earlier the day of her initial contact. She reported she had observed one animal (Subform III, #1) groom or lick the product from its coat and had vomited. Another animal (Subform III, #2) had been observed to be lethargic. The reporter had also indicated she had some irritation to her finger following application. The reporter was advised of proper decontamination for all parties and supportive/symptomatic care that may be offered. On follow up the pet owner described her symptoms resolving by the end of the same evening she had contacted the registrant. She had bathed the animals with a hand dishwashing liquid and on had spontaneously resolved with two hours (Subform III, #1) the other she did not comment on. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

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

Unknown

6. Age (provide a range if necessary )

0.41

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

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• General
  • Symptom - Lethargy

12. How long did the symptoms last?

Unknown / Inconnu

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

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

1-27438968- The reporter, a pet owner, indicated she and her animals were exposed to and insecticidal product containing the active ingredient methoprene. The pet owner indicated she had applied the product to her five month kittens earlier the day of her initial contact. She reported she had observed one animal (Subform III, #1) groom or lick the product from its coat and had vomited. Another animal (Subform III, #2) had been observed to be lethargic. The reporter had also indicated she had some irritation to her finger following application. The reporter was advised of proper decontamination for all parties and supportive/symptomatic care that may be offered. On follow up the pet owner described her symptoms resolving by the end of the same evening she had contacted the registrant. She had bathed the animals with a hand dishwashing liquid and on had spontaneously resolved with two hours (Subform III, #1) the other she did not comment on. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here