Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2116

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-37161818

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.

20-MAY-14

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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. 2596-79

Product Name: UltraGuard Flea/Tick Powder for Dogs 4 ounces

  • Active Ingredient(s)
    • TETRACHLORVINPHOS
      • Guarantee/concentration 3.3 %

7. b) Type of formulation.

Dust

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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

70

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Fecal incontinence

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

1-37161818 - The reporter, a pet owner, indicated that her three dogs were exposed to an insecticidal powder containing the active ingredient tetrachlorvinphos. The reporter indicated that she applied the product to her 7-year-old, female, 70 pound mixed breed dog (Subform III #1) and to her two 1-year-old, 50 pound mixed breed dogs about 6 months prior to initial contact with the company. The reporter indicates that after the product was applied to her 7-year-old dog the dog could not get up, she lost control of her bowels and she died in less than one week. No veterinary care was sought. The reporter also indicates that her other 2 dogs became lethargic after product application and per the reporter they continue to act abnormally; as if they are mentally compromised. The reporter was advised that the described symptoms are not consistent with use of the product. Veterinary care was recommended for the two dogs that were not acting normally. 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