Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1492

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

27-JAN-13

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-150

Product Name: Hartz Ultraguard Pro Flea and Tick for Dogs and Puppies under 15 pound

• Active Ingredient(s)
  • (S)-METHOPRENE
  • D-PHENOTHRIN

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-504-2596

Product Name: Hartz Ultraguard Pro Flea and Tick for cats

• Active Ingredient(s)
  • (S)-METHOPRENE
  • ETOFENPROX

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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).

After reading the instructions my other placed one application (each is in its own single dose container) between the shoulder blades of each of her dog small dogs and her cat . You apply this by separating the animal hair and squeezing the clear solution between the should blades of the animal.

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu Yorkie and Shih Tzu Poodle

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Abnormal behaviour
  • Specify - rolling around

• Skin
  • Symptom - Burns (superficial)

• Gastrointestinal System
  • Symptom - Diarrhea

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

Both dogs experienced burns where it was applied. Both dogs began rolling around trying to get it off. The cat wouldnt allow you to touch her but would scream in pain. The cat had seizures for 24 hours and every time she moved her front paw it would retract and go stiff. The cat is still having tremors in her back legs over a week later. One of the dogs experienced sever diarrhea lasting one day.Applied as directed by instructions on the box. When I contacted Hartz customer service they put me through to their vet who informed me that we were doing what we could (bathing the animals and giving them water) and that it was common side effects. The box lists may cause irritation. The company basically admitted they know this happens often and death isnt common.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Cat / Chat

3. Breed

Mix breed cat

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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 - Seizure
  • Symptom - Stiffness
  • Symptom - Muscle tremors

• General
  • Symptom - Vocalizing
  • Symptom - Pain
  • Symptom - Abnormal behaviour

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Recvrd resid.effects/Rétabli séquelles

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

Both dogs experienced burns where it was applied. Both dogs began rolling around trying to get it off. The cat wouldnt allow you to touch her but would scream in pain. The cat had seizures for 24 hours and every time she moved her front paw it would retract and go stiff. The cat is still having tremors in her back legs over a week later. One of the dogs experienced sever diarrhea lasting one day.Applied as directed by instructions on the box. When I contacted Hartz customer service they put me through to their vet who informed me that we were doing what we could (bathing the animals and giving them water) and that it was common side effects. The box lists may cause irritation. The company basically admitted they know this happens often and death isnt common.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu Yorkie and Shih Tzu Poodle

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Abnormal behaviour

• Skin
  • Symptom - Burns (superficial)
  • Specify - rolling around

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

Both dogs experienced burns where it was applied. Both dogs began rolling around trying to get it off. The cat wouldnt allow you to touch her but would scream in pain. The cat had seizures for 24 hours and every time she moved her front paw it would retract and go stiff. The cat is still having tremors in her back legs over a week later. One of the dogs experienced sever diarrhea lasting one day.Applied as directed by instructions on the box. When I contacted Hartz customer service they put me through to their vet who informed me that we were doing what we could (bathing the animals and giving them water) and that it was common side effects. The box lists may cause irritation. The company basically admitted they know this happens often and death isnt common.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here