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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0068
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-28163743
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.
22-NOV-115. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
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. PMRA Submission No. EPA Registration No. 2596-151
Product Name: UltraGuard Flea Tick Drops for Dogs Puppies Over 60 lbs
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration 85.7 %
- D-PHENOTHRIN
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Shih Tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
13
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Skin
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 - Seizure
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
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
1-28163743- The reporter, a pet owner, indicates her animal was exposed to an insecticidal product with the active ingredient phenothrin. The reporter stated she had applied the product to her thirteen year female ten pound Shih Tzu dog intermittently over the past year. The caller reported she would apply only part of the product labeled for 60+ pounds dogs to her 10 pound dog monthly over the course of 3-4 months. She reported she had last applied the product to her animal three months prior to her initial contact. Two months prior to her initial contact the animal developed seizure activity, the animal was brought to the veterinarians office where it died. The pet owner was advised the signs, outcome and time line were inconsistent with the toxicity profile of the active ingredient despite the described misuse. The pet owner was advised of registrant supported necropsy that might assist in determining the cause of death. It is unclear if the animals remains were submitted for evaluation. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
