Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5263
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-27538662
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.
26-SEP-11
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
22-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. 29283
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Pro Flea Tick Drops for Dogs Puppies Under 30 lbs
- Active Ingredient(s)
- (S)-METHOPRENE
- 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
Mixed breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Skin
- Symptom - Pruritus
- Symptom - Lesion
- Specify - scab
- General
- Symptom - Abnormal behaviour
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
1-27538662- The reporter, a pet owner, indicated her animal was exposed to an insecticidal product containing the active ingredients permethrin and methoprene. The reporter stated she applied the product to her four year twelve pound mixed breed dog four days prior to the initial contact with the registrant. She noted by later the same day the animal was clinging to her and would not go outside. She also noted the animal scratching ant the application site. The day following application she noted at the application site a scab the size of a dollar bill. She had cleansed the area with peroxide and had an appointment with the veterinarian the next day. The pet owner was advised to bathe the animal with a non insecticidal shampoo and proceed to the veterinarian as planned. 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