Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-3376
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-37950231
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.
29-JUL-14
5. Location of incident.
Country: UNITED STATES
Prov / State: IOWA
6. Date incident was first observed.
25-JUL-14
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. 2596-167
Product Name: Ultraguard Flea/Tick Prevention for Dogs/ Puppies 61-150 pounds
- Active Ingredient(s)
- ETOFENPROX
- Guarantee/concentration 55 %
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration 1 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration 10 %
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
Other
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 )
11
7. Weight (provide a range if necessary )
Unknown
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 - Difficulty getting up
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
1-37950231 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticide containing the active ingredients etofenprox, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The reporters husband applied the product to their 11 year old, female dog to treat an active flea infestation 4 days prior to initial contact with the registrant. The following day the dog vomited, had a glazed look in his eye and laid down. The reporter bathed the dog with a hand dish washing liquid but after the bath the dogs symptoms worsened. It began to pant, seemed unable to stand, refused to eat and became lethargic. The reporter was advised that there are numerous possible causes for the described symptoms and without pre-mortem diagnostics or a necropsy the cause for death cannot be determined. A severe flea infestation with associated anemia may present with similar symptoms. 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