Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-1605
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-36660964
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.
04-APR-145. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
6. Date incident was first observed.
03-APR-14Product 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. 2596-84
Product Name: UltraGuard Flea/Tick Collar for Dogs White
- Active Ingredient(s)
- TETRACHLORVINPHOS
- Guarantee/concentration 14.55 %
- TETRACHLORVINPHOS
7. b) Type of formulation.
Other (specify)
Impregnated collarApplication 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
Mixed breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.33
7. Weight (provide a range if necessary )
13.5
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Death
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
- Eye
- Symptom - Pupil dilation
- General
- Symptom - Malaise
- Gastrointestinal System
- Symptom - Bloody stool
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
1-36660964 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal collar containing the active ingredient tetrachlorvinphos. The reporter placed the collar on his 4-month-old, 13.5 pound, female mixed breed dog one day prior to initial contact with the registrant. After the collar was applied the dog chewed it off. The dog did not ingest the collar but it did lick some of the powder that was on the collar. On the morning of initial contact the reporter indicated that his dog had vomited 3 times had had 2 bouts of diarrhea and her pupils were large. The reporter was advised that the powder on the collar is not meant to be ingested and immediate veterinary care was recommended. On follow-up call, three days later, the reporter indicated that the puppy had developed bloody stool and then died one night prior to the follow-up call. The reporter had not sought veterinary care for the dog. The reporter also indicated that the puppy had not received any vaccines nor had it ever seen a veterinarian. The reporter was advised that given the vaccine status of the dog and the described symptoms the dogs death may have been secondary to parvo virus. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
