Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1436
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-29182722
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.
27-FEB-12
5. Location of incident.
Country: UNITED STATES
Prov / State: ILLINOIS
6. Date incident was first observed.
26-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.
PMRA Submission No.
EPA Registration No. 2596-22
Product Name: UltraGuard Rid Flea Dog Shampoo Refreshing Fresh Citrus
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .149 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .089 %
- PYRETHRINS
- Guarantee/concentration .045 %
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
Yorkshire Terrier (Yorkie)
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Difficulty getting up
- Symptom - Rigidity
- Symptom - Muscle tremors
- General
- Symptom - Fever
- 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
1-29182722- The reporter, a pet owner, indicated her animal was exposed to an insecticidal product containing the active ingredients pyrethrins, piperonyl butoxide, and n-octyl bicycloheptene. The pet owner indicated she had applied the pet shampoo to her two year female eight pound Yorkshire terrier dog the day prior to her initial report. The still lactating dog demonstrated signs of muscle rigidity within one hour of use. The animal was brought to the veterinarian where difficulty rising, tremor, panting, seizure and fever were observed. The veterinarian placed an intravenous catheter and had given some unspecified fluid. But the animal died before further treatment or diagnostics could be offered. The pet owner indicated she had used this product on the animal prior with no concerns. This product is not labeled for use on pregnant or lactating animals. Despite this fact neither the signs nor the outcome seen would be expected. Paperwork for registrant supported necropsy was faxed to the callers veterinarian. It is unclear if the animals remains were submitted. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here