Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-3885
2. Registrant Information.
Registrant Reference Number: 1408180-000028
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.
18-AUG-14
5. Location of incident.
Country: CANADA
Prov / State: NEWFOUNDLAND
6. Date incident was first observed.
27-OCT-13
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. 25902
PMRA Submission No.
EPA Registration No.
Product Name: SERGEANTS SKIP SHAMPOOING ANTI-PUCES ET TIQUES POUR CHIENS
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
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 used. No details were given. We have not been able to establish that our product was used
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
Shih Tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
5.4
kg
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 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
The animal was treated with Methocarbamol and sent home with a prescription of Advantage Multi 20 (imidacloprid + moxidectin) (october 27, 2013). The animal was doing well. Returned to the veterinarian 2 days later. Vet observed strong pulse, muscle twitching in neck area, mild eye twitching, rigid stance (october 29, 2013). Metacam injection was administered and a prescription for trazodone and methocarbamol was given.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
The animal was examined by the veterinarian on october 27 and 29. We were provided a copy of the veterinarian report for the october 29th visit only. No report was provided for the first visit.