Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-1909
2. Registrant Information.
Registrant Reference Number: 337233
Registrant Name (Full Legal Name no abbreviations): Hartz Canada, Inc.
Address: 1125 Talbot Street
City: St. Thomas
Prov / State: ON
Country: Canada
Postal Code: N5P 3W7
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
05-DEC-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
28-OCT-12
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. 25923
PMRA Submission No.
EPA Registration No.
Product Name: HARTZ ULTRAGUARD FLEA TICK DROPS FOR DOGS PUPPIES WEIGHING UP TO 14
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
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).
Followed directions as per label, applied one of three tubes between the shoulder blades in the evening. Next day reaction, which persisted for 6 days. Took dog to Vet, on day 6 after treatment. Vet noticed redness under hair where product applied. Upon hair removal lesion found. Vet concluded that product caused chemical burn skin damage, causing pain and suffering and inhibiting dogs normal activity and mobility. Vet washed and remaining product, and applied topical antibiotic. Vet prescribed oral antibiotics,
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
Dog / Chien
3. Breed
Mixed Breed, Maltese Mix Dog
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
1.5
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Nervous and Muscular Systems
- Symptom - Difficulty walking
- Specify - reluctant to walk, prefers to lay down, refused to eat or drink unless hand fed, does not come when called
- Skin
- Symptom - Lesion
- Symptom - Red skin
- Symptom - Burns (superficial)
- Specify - chemical burn
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
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
Followed directions as per label, applied one of three tubes between the shoulder blades in the evening. Next day reaction, which persisted for 6 days. Took dog to Vet, on day 6 after treatment. Vet noticed redness under hair where product applied. Upon hair removal lesion found. Vet concluded that product caused chemical burn skin damage, causing pain and suffering and inhibiting dogs normal activity and mobility. Vet washed and remaining product, and applied topical antibiotic. Vet prescribed oral antibiotics. Dog recovered after several weeks.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here