Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5256
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-27433344
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.
14-SEP-11
5. Location of incident.
Country: UNITED STATES
Prov / State: MICHIGAN
6. Date incident was first observed.
13-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 2596-83
Product Name: UltraGuard Flea Tick Collar for Cats Safety Release Snap Reflecting
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
7. b) Type of formulation.
Other (specify)
pet flea tick collar
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
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
6
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Respiratory System
- Symptom - Shortness of breath
- General
- Symptom - Vocalizing
- 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
1-27433344- The reporter, a pet owner, indicated her animal was exposed to an insecticide containing the active ingredients tetrachlorvinphos. The pet owner indicated she had applied the product to her two year six pound female cat three days prior to her initial contact with the registrant. She had noted one day prior to her initial contact that the animal had been vocalizing, lethargic and had breathing difficulties. The pet owner was advised to seek immediate veterinary assistance. The signs seen would not be expected following use of the product as labeled. On routine follow up one day later the pet owner indicated the animal had died before she could obtain veterinary assistance. The reporter was advised of registrant supported necropsy that may 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