Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4285
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-38140587
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.
15-AUG-14
5. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
14-AUG-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. 30735
PMRA Submission No.
EPA Registration No.
Product Name: Ultraguard Flea/Tick Treatment for Dogs/Puppies greater than 28kgs
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: 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
Bernese Mountain Dog
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
110
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
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
1-38140587 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticide containing the active ingredient phenothrin. The reporter applied the product to her 5-year-old, 110 pound, male Bernese mountain dog one day prior to initial contact with the registrant. At the time of the initial call the reporter indicated that the dog was scratching all over. The reporter also stated that she thinks her dog may have been scratching excessively one month ago after she used the same product. The reporter was advised that the product may cause transient parasthesia in sensitive animals. Bathing with a hand dishwashing soap was recommended. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here