Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4641
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-31511867
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.
12-SEP-12
5. Location of incident.
Country: UNITED STATES
Prov / State: ARIZONA
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.
PMRA Submission No.
EPA Registration No. 2596-83
Product Name: UltraGuard Flea and Tick Collar for Cats Safety Release Snap
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
7. b) Type of formulation.
Other (specify)
Collar
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
Cat / Chat
3. Breed
Domestic Longhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
6.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Muscle weakness
- General
- Symptom - Vocalizing
- 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
1-31511867 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal collar containing the active ingredient tetrachlorvinphos. The pet owner reported that she placed a collar on all 14 of her cats approximately 11 days prior to initial contact with the registrant and 3 days prior to initial contact the reporter was holding her 6-year-old female cat while it cried out and then her legs gave out and she died suddenly. The reporter indicated that just before her cat died she did remove the collar. No symptoms were noted in any of the other thirteen cats in the household who were also wearing the collar. The reporter was advised that there are numerous possible causes for sudden death and further testing was recommended to help determine the underlying cause for her cats death. The reporter declined any further testing indicating that her cat was already buried. 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