Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-3727
2. Registrant Information.
Registrant Reference Number: 130703-000054
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.
03-JUL-13
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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
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).
The entire tube was apply from the shoulder down to the tail of the cat
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, long hair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
4
lbs
8. Route(s) of exposure
Skin
Oral
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Respiratory System
- Symptom - Difficulty Breathing
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Other
- Specify - blue and purple tongue
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
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 owner called Sergeant's customer service phone line. Indicating that the cat licked the product and had a blue and purple tongue and had difficulty breathing, Mrs (name) was directed to go see her veterinarian immediately. Mrs (name) did not went to the veternarian. Later the cat began to convulsed and died about 8 hours after the application of the product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The client mentioned that the cat was previously exposed to the product had side effect, no mention which one. We ask about why she did not follow direction on how to apply the product and told us this is how her retailer explained she should be applying product, at the same time claming to have read our instruction (which direct to only applied between should blade). We tried at numerous occasions to have more detail at three occasions.