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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1433
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-29058921
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.
15-FEB-125. Location of incident.
Country: UNITED STATES
Prov / State: CONNECTICUT
6. Date incident was first observed.
15-FEB-12Product 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. 2596-78
Product Name: UltraGuard Flea Tick Powder for Cats
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 3.3 %
- TETRACHLORVINPHOS
7. b) Type of formulation.
Dust
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 Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
5
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- General
- Symptom - Lethargy
- 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?
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
1-29058921- The reporter, a pet owner, indicates her animal may have been exposed to a insecticidal product containing the active ingredient tetrachlorvinphos. The pet owner indicated she hd applied the product, a topical flea and tick preparation, to her five year twelve pound male domestic shorthair cat one day prior to her initial contact with the registrant. The pet was reported to have developed the signs of diarrhea, vomiting and lethargy the following day. The pet owner was advised to bathe the animal and seek veterinary care. The signs were not expected to be related to the use of the product. Later the same day the pet owners veterinarian called reporting the same signs. The veterinarian was offered two diagnostic tests that may be used to rule out the involvement of the active ingredient in the animals illness. Decontamination was described. The veterinarian was encouraged to seek other diagnosis as the pets illness was likely not related to the use of the product. The next day the pet owner was contacted. The pet was given intravenous fluid at the veterinary office. All other diagnostics and treatments were declined due to cost. The animal was taken home where it died. The pet was buried, no necropsy was performed. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
