Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6933
2. Registrant Information.
Registrant Reference Number: 130917-000037
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.
17-SEP-13
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
18-AUG-12
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. 27667
PMRA Submission No.
EPA Registration No.
Product Name: Sergeants Flea Collar For Cats and Kittens with Integral Buckle
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: 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 the product was applied correctly
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Persian
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.66
7. Weight (provide a range if necessary )
7
lbs
8. Route(s) of exposure
Skin
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
12. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
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
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
L'animal commencer avoir des symptomes d'hyperexcitation rapidement apres que le collier soit install sur l'animal.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Nous n'avons pas ete en mesure de d'terminer si l'incident est plutot relie au fait que le chat n'a jamais porte de collier avant cette pisode ou que c'est une reaction au collier lui meme