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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2013-4267

2. Registrant Information.

Registrant Reference Number: 1 34422341

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-JUL-13

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

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.       PMRA Submission No.       EPA Registration No. 2596-153

Product Name: Ultra guard Rid Flea Tick Shampoo with Oatmeal for Dogs

  • Active Ingredient(s)
    • D-PHENOTHRIN
      • Guarantee/concentration .25 %

7. b) Type of formulation.

Liquid

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

Unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

4.5

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

  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • Gastrointestinal System
    • Symptom - Salivating excessively

12. How long did the symptoms last?

Persisted until death

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

1 34422341 The reporter, a pet owner, indicated that her dog was exposed to an insecticidal shampoo containing the active ingredient phenothrin. The reporter indicated that she bathed her 5 year old, 4.5 pound, female dog with the shampoo one hour prior to initial contact with the registrant and soon after bathing her dog she found the dog seizing and foaming at the mouth. The dog then died from the seizure. It was recommended that the reporter submit her dog for necropsy to help determine the cause of death. The callers veterinarian performed a necropsy and did not see any gross lesions. The kidney, brain and liver were submitted for evaluation by a pathologist. The results are currently pending. No further information is available.


To be determined by Registrant

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

Death

19. Provide supplemental information here

Status update: 1 34422341 The kidney, liver, brain and skin were submitted to (name) Veterinary Diagnostic Laboratory for examination and toxicology screening. No identifiable lesions were evident on gross examination or by histopathology. No toxicants were detectable via Gas chromatography mass spectrometry screening. No further information is available.