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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-1624
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-32563341
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.
26-JAN-135. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
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. 25922 PMRA Submission No. EPA Registration No.
Product Name: Ultraguard Flea/Tick Drops for Dogs/Puppies Over 30 lbs.
- 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
Golden Retriever
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
62
kg
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Paralysis
- Respiratory System
- Symptom - Difficulty Breathing
- General
- Symptom - Lethargy
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
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
1-32558361 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal product containing the active ingredient permethrin. The reporter indicated that one month prior to initial contact with the registrant he applied a spot-on product to his 10 year old, female spayed, golden retriever. Within two days of product application the dog became lethargic which the veterinarian treated with antibiotics. The caller reapplied the product 7 days prior to initial contact with the registrant and two days after product application the dog became lethargic had difficulty breathing and per the reporter had hind limb paralysis. The veterinarian has since run blood work which per the reporter was normal. The dog was bathed and is currently being treated with antibiotics, vitamins and prednisone. The reporter was advised that the described symptoms would not be expected from exposure to the product. Excessive exposure to the active ingredient may cause generalized neurologic symptoms but hind limb paralysis is not consistent with product exposure. The caller was advised to continue working with his veterinarian for diagnosis and treatment of any ongoing symptoms. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
