Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5565
2. Registrant Information.
Registrant Reference Number: 274588
Registrant Name (Full Legal Name no abbreviations): Hartz Canada, Inc.
Address: 1125 Talbot Street
City: St. Thomas
Prov / State: ON
Country: Canada
Postal Code: N5P 3W7
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
02-AUG-11
5. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
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. 26491
PMRA Submission No.
EPA Registration No.
Product Name: HARTZ ULTRAGUARD ONE SPOT TREATMENT FOR CATS KITTENS
PMRA Registration No. 25922
PMRA Submission No.
EPA Registration No.
Product Name: HARTZ ULTRAGUARD FLEA TICK DROPS FOR DOGS PUPPIES OVER 14KG (30LBS
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
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
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
N/A
4. Number of animals affected
2
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Depression
- Specify - depressed
- General
- Symptom - Vocalizing
- Specify - meowing
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
have three cats and one dog. bought 2 packs for the cats. and 1 pack for the dog. I used the product once on each animal. After putting on the product my cats meowed and the dog was so very depressed. I did have to treat my animals with another product. I had to put my cats in a bath got clawed and scratch in the process . One of my cats has not truly come out of it yet. She is not herself always sleeping. Now she is lossing her hair where i used the product.
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
Dog / Chien
3. Breed
N/A
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Depression
- Specify - depressed
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
have three cats and one dog. bought 2 packs for the cats. and 1 pack for the dog. I used the product once on each animal. After putting on the product my cats meowed and the dog was so very depressed. I did have to treat my animals with another product. I had to put my cats in a bath got clawed and scratch in the process . One of my cats has not truly come out of it yet. She is not herself always sleeping. Now she is lossing her hair where i used the product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here