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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3726

2. Registrant Information.

Registrant Reference Number: 130521-000024

Registrant Name (Full Legal Name no abbreviations): Rolf C. Hagen Inc.

Address: 20500 Trans Canada Highway

City: Baie d'Urfe

Prov / State: Quebec

Country: Canada

Postal Code: H9X0A2

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

21-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

02-JUL-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. 28610      PMRA Submission No.       EPA Registration No.

Product Name: Sergeant's Pretech Squeeze-On for Cats and Kitten

  • Active Ingredient(s)
    • PYRIPROXYFEN

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1.5

Units: mL

10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

According to the owner as instruction requires it. Owner also treat her dog with Sergeant Squeeze on for large dog that contains permethrin, and the cat had access to dog bedding after treatment.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic, short hair

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

6.6

kg

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Trembling
  • Gastrointestinal System
    • Symptom - Drooling

12. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

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

The following the onset of the symptom the owner washed the cat. The symptom did not abate. Went to the veterinarian the following day. Treated with diazepam 0.5mg/kg/hr (IV), than methocarbamol 500mg the symptoms and took 2 weeks for all symptom to


To be determined by Registrant

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

Major

19. Provide supplemental information here

Mrs (name) failed to segregate both cat and dog after treatment (they share the same bedding area after treatment), so it is very likely that the cat was exposed to permethrin.