Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4712
2. Registrant Information.
Registrant Reference Number: 120816-000066
Registrant Name (Full Legal Name no abbreviations): Rolf C. Hagen Inc.
Address: 20500 Trans Canada Highway
City: Baie d'Urfe
Prov / State: Quebec
Country: Canada
Postal Code: H9X0A2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
16-AUG-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. 28610
PMRA Submission No.
EPA Registration No.
Product Name: Sergeant's Pretech Squeeze-On for Cats and Kitten
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1.5
Units: mL
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).
According to the owner the product was applied correctly
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
6.8
kg
8. Route(s) of exposure
Skin
Unknown
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
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
Owner and cat consult vet clinic Veterinary Emergency Clinic (area), (vet clinic address) . Symptoms were mild diarrhea as well as panting. Lethargic behaviour for two days. Third day consult vet and the exam were all normal
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here