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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-3052
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:
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.
29-JUL-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
14-JUL-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. 25923 PMRA Submission No. EPA Registration No.
Product Name: UltraGuard Flea Tick Drops for Dogs Puppies
- 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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
5
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
- General
- Symptom - Abnormal behaviour
- Specify - kicking back legs and bucking
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
1-30877085- The reporter, a pet owner, indicated her animal had been exposed to an insecticide containing the active ingredient permethrin. The reporter indicated she had applied the product to her ten month female five pound Chihuahua dog two day prior to her initial contact with the registrant. The pet owner indicated the animal had been kicking her back legs since the point of application. The pet owner had bathed the animal several times following application. The pet owner had contacted her veterinarian by phone but indicated no care was provided. The pet owner was advised the signs seen were not consistent with the expectation of the active ingredient or the finished product. It was recommended she seek veterinary care if the animals signs were to worsen or persist. No follow up was obtained from the reporter. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
