Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2749
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-30370715
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.
04-JUN-12
5. Location of incident.
Country: UNITED STATES
Prov / State: GEORGIA
6. Date incident was first observed.
02-JUN-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 anTick Shampoo for Dogs Clean Fresh Scent 18 fl oz
- 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
Basset Hound
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
12
7. Weight (provide a range if necessary )
70
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
- Nervous and Muscular Systems
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
1-30370715The reporter, a pet owner, indicated her dog was exposed to a flea and tick shampoo containing pyrethrins, piperonyl butoxide and n-Octyl bicycloheptene dicarboximide. The pet owner reports applying this shampoo to her male, 12-year-old, Basset hound at 2pm, 2 days prior to contacting the registrant. The evening after shampooing the dog the reporter noted that the dog had seizures and he then passed away on the following evening. The dog was not seen by a veterinarian. A necropsy was offered but the dog had already been buried. No additional information is known.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here