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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0060
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-28004485
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.
04-NOV-115. Location of incident.
Country: UNITED STATES
Prov / State: MICHIGAN
6. Date incident was first observed.
26-OCT-11Product 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. 2596-140
Product Name: UltraGuard Plus Flea Tick Spray for Cats
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration 1.08 %
- TETRACHLORVINPHOS
- Guarantee/concentration .07 %
- (S)-METHOPRENE
7. b) Type of formulation.
Liquid
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
Domestic Longhair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
11
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Seizure
- General
- 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
1-28004485- The reporter, a pet owner, indicated his animal had been exposed to an insecticidal product containing the active ingredients tetrachlorvinphos and methoprene. The pet owner stated he had applied the product to his eleven year fourteen pound male domestic longhair cat for two months prior to his initial contact with the registrant. The reporter indicated he had applied the product last to the animal one and one half weeks prior to his initial contact with the registrant. He indicated he had washed the product off the animal that same night as he did not want it to remain on the animal as a residual. He reports the morning after the final application the animal came into the bathroom to greet him in the morning as he typically would lay down on his side had a seizure and died. The pet owner state the animal was not brought to the veterinarian; no necropsy was done and had been buried at the point of the call/initial contact. The pet owner was advised the signs seen and the out come seen would be unexpected following use of the product as labeled. He was advised something else was likely affecting the animal¿s health. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
