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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2064

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-32864949

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.

25-FEB-13

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. 26133      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Flea/Tick Shampoo for Dogs White Tea

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PIPERONYL BUTOXIDE
    • PYRETHRINS

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

Dachshund

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

22

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 - Trembling
  • General
    • Symptom - Pain

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

1-32864949 - The reporter, a veterinary technician, indicated that a dog was exposed to an insecticidal shampoo containing the active ingredients pyrethrins, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. Per the reporter, the pet owner shampooed her 9-year-old, female spayed, 22 pound Dachshund with the product sometime in the week prior to initial contact with the registrant. The dog was taken to the veterinarian four days prior to initial contact with the registrant where they took x-rays of the spine because they were concerned about back issues but no lesions were evident on the x-rays. On the day of initial contact they are still working on diagnosing a cause for the dogs symptoms and spinal issues were still a consideration but the owners were concerned about the dog's exposure to the registrant shampoo. The caller was advised that the duration and time frame of the described symptoms is not consistent with product exposure. Additional work-up was recommended to determine the underlying cause for the dogs symptoms. No further information is available.


To be determined by Registrant

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

Minor

19. Provide supplemental information here