Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1430
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-28982696
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.
08-FEB-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
07-FEB-12
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. 26133
PMRA Submission No.
EPA Registration No.
Product Name: UltraGuard Flea Tick Shampoo for Dogs
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- PIPERONYL BUTOXIDE
- PYRETHRINS
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
Shih Tzu
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
20
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
- Skin
- Symptom - Erythema
- Symptom - Pruritus
- Symptom - Hair loss
12. How long did the symptoms last?
Unknown / Inconnu
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
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
1-28982696- The reporter, a pet owner, indicates his animal was exposed to an insecticidal product containing the active ingredients pyrethrins, piperonyl butoxide, and n-octyl bicycloheptene Dicarboximide. The reporter indicted he had applied the product to his three year male twenty pound Shih Tzu dog the day prior to his initial report. He indicated that same evening he had noted dermal redness, itch and hair that was either missing or had been pulled out by the animal. The pet owner had bathed the animal in baby shampoo and given it two garlic oil capsules. The pet owner reported she had used the product last (unspecified date) she had noted the same reaction. The signs seen would not be expected following routine use per the label. It is possible the animal may have a hypersensitivity. 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