Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1952
2. Registrant Information.
Registrant Reference Number: PROSAR Case #1-29710833
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.
07-APR-12
5. Location of incident.
Country: UNITED STATES
Prov / State: MASSACHUSETTS
6. Date incident was first observed.
05-APR-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. 2596-150
Product Name: UltraGuard Plus Flea and Tick Drops Plus for Dogs and Puppies 4-15 lbs
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration 2.3 %
- D-PHENOTHRIN
- Guarantee/concentration 85.7 %
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
Mixed Breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
14
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
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- 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.
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
1-29710833- The reporter, a pet owner, indicated her animal had been exposed to an insecticidal product containing the active ingredients phenothrin and methoprene. The reporter indicated she had applied the product to her fourteen year old female ten pound mixed breed dog ten days prior to her initial report. The pet owner stated seven days later the animal refused to eat and was lethargic. The pet owner was advised the product is not labeled for elderly animals. She was advised of proper decontamination techniques and to seek veterinary assistance. On follow up two days later the pet owner indicated the animal had died that morning. She had not taken it to the veterinarian. The signs seen and outcome seen would not be expected following proper use of the product per the label. 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