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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3171

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-33538364

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.

02-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

02-MAY-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. 26489      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Plus Flea/Tick Drops for Dogs/Puppies under 30 lbs

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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

7

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Trembling
    • Symptom - Ataxia
  • Skin
    • Symptom - Red skin
  • Nervous and Muscular Systems
    • Symptom - Muscle tremors
    • Symptom - Difficulty walking

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

1-33538364 - The reporter, a pet owner, indicated that his dog was exposed to a spot-on insecticide containing the active ingredient permethrin and methoprene. The reporter states that he applied the product to his 11 year old, 7 pound, female, Shih Tzu and toy poodle mixed breed one day prior to initial contact with the registrant. A couple of hours after product application the reporters dog was tremoring and having problems walking. The reporter bathed the dog with a non-insecticidal shampoo but the symptoms were still present at the time of the initial call. The reporter was advised to seek veterinary care for any ongoing neurologic symptoms. Later, during the same day, the dogs veterinarian called indicating that the dog was mildly ataxic and a little erythemic. The veterinarian indicated that the dog had a history of allergies and the erythema was likely secondary to the dogs known allergies. A bath with a non-insecticidal shampoo was recommended along with supportive care as needed. No further information is available.


To be determined by Registrant

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

Moderate

19. Provide supplemental information here