Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-2755
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-33298937
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.
15-APR-13
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
10-APR-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)
PMRA Registration No. 25922
PMRA Submission No.
EPA Registration No.
Product Name: Ultraguard Flea/Tick Drops for Dogs/Puppies Over 30 lbs
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?
Yes
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
Male
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
75
lbs
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
- Skin
- Symptom - Other
- Specify - Infection
- Symptom - Irritated skin
- Symptom - Red skin
- Symptom - Hair loss
- Symptom - Lesion
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?
No
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
1-33215703 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticide containing the active ingredient permethrin. The reporter states that she applied this product on her dog eight days prior to initial contact with the registrant and then five days prior to initial contact the reporter noted that her dog had hair loss, red and damaged skin at the application site. The reporter took her dog to the veterinarian that same day where the area was clipped and scrubbed. After clipping they noted puss oozing from the lesion on the dogs neck and the dog was started on an oral antibiotic (Novo-Lexin). The reporter was advised that some animals may have an unrecognized sensitivity to the product and she should avoid use of this product and products with similar ingredients in the future. 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