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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-5569
2. Registrant Information.
Registrant Reference Number: 1-34809734
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.
Human
Domestic Animal
4. Date registrant was first informed of the incident.
02-SEP-135. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
09-AUG-13Product 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. 29283 PMRA Submission No. EPA Registration No.
Product Name: UltraGuard Pro 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 II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Burn on the eye
- Gastrointestinal System
- Symptom - Other
- Specify - Intestinal infection
- Renal System
- Symptom - Other
- Specify - Bladder infection
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Eye
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
1-34809734 - The reporter, a pet owner, indicated that both she and her dog were exposed to a spot-on insecticide containing the active ingredients permethrin and methoprene. The reporter applied the product to her 3-year-old, 8 pound, male neutered Pomeranian (Subform III #2) twenty four days prior to initial contact with the registrant and by the next day the dog was scratching and had hair loss. The reporter bathed the dog that day and while bathing the dog the reporter (Subform III #1) thought she got some of the product in her eye. The dog was brought to the veterinarian for what the reporter described was a third degree burn and at the time of the initial call the dog still had a scar where the hair had not regrown. The reporter indicated that she went to the doctor for her ocular exposure. The doctor flushed her eye and prescribed an unknown eye drop which was applied for 10 days. Also, per the reporter, the ocular exposure had resulted in the product seeping into her blood stream and consequently the exposure caused her to suffer from a bladder and an intestinal infection. The reporter was advised that the product is an irritant but is not a corrosive and would not be expected to cause the described symptoms. Some animals are allergic to the product and transient dermal effects may be seen in these animals. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Pomeranian
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Skin
- Symptom - Hair loss
- Symptom - Itchy skin
- Symptom - Burns (2nd or 3rd degree)
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
1-34809734 - The reporter, a pet owner, indicated that both she and her dog were exposed to a spot-on insecticide containing the active ingredients permethrin and methoprene. The reporter applied the product to her 3-year-old, 8 pound, male neutered Pomeranian (Subform III #2) twenty four days prior to initial contact with the registrant and by the next day the dog was scratching and had hair loss. The reporter bathed the dog that day and while bathing the dog the reporter (Subform III #1) thought she got some of the product in her eye. The dog was brought to the veterinarian for what the reporter described was a third degree burn and at the time of the initial call the dog still had a scar where the hair had not regrown. The reporter indicated that she went to the doctor for her ocular exposure. The doctor flushed her eye and prescribed an unknown eye drop which was applied for 10 days. Also, per the reporter, the ocular exposure had resulted in the product seeping into her blood stream and consequently the exposure caused her to suffer from a bladder and an intestinal infection. The reporter was advised that the product is an irritant but is not a corrosive and would not be expected to cause the described symptoms. Some animals are allergic to the product and transient dermal effects may be seen in these animals. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
