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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2110

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-29357771

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.

Human

4. Date registrant was first informed of the incident.

12-MAR-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 25922      PMRA Submission No.       EPA Registration No.

Product Name: Control Pet Care System Once A Month Flea Tick Treatment for Dogs

  • Active Ingredient(s)
    • PERMETHRIN

PMRA Registration No. 25922      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea TIck Drops for Dogs Puppies Over 30 lbs

  • Active Ingredient(s)
    • PERMETHRIN

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Nervous and Muscular Systems
    • Symptom - Headache

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-29357771- The caller reports she had been exposed to two insecticidal products of similar formulation, both containing permethrin. The reporter indicated she had not noted an aroma when she had previously purchased these two products for her dogs. She did when recently opening a container of the product. She had as a consequence opened six packages of the product and placed the contents on slips of paper. She has subsequently sniffed them each to assess them for an aroma. Following this she had developed a head ache. The caller was advised to discontinue the behavior, remove herself to fresh air and seek medical assistance if her symptoms were to worsen or persist. No further information is available. Nonspecific symptoms of respiratory irritation, nausea, or headache may be seen following intentionally inhaling this product. They would be expected to spontaneously resolve following discontinuation and removal to fresh air.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

pet owner (caller resides with animals)