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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1721

2. Registrant Information.

Registrant Reference Number: 150204-37

Registrant Name (Full Legal Name no abbreviations): Rolf C Hagen Inc

Address: 20500 Trans Canada Hwy

City: Baie d'Urf¿¿¿¿

Prov / State: Qc

Country: Canada

Postal Code: H9X 0A2

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

04-FEB-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

26-JAN-15

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. 25903      PMRA Submission No.       EPA Registration No.

Product Name: Sergeant's Skip Flea and Tick Shampoo for Cat

  • 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: 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).

No information was provided has how much of the shampoo was used onto the cat.

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

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

14

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

>8 hrs <= 24 hrs / >8 h <= 24 h

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Vomiting

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

1

Day(s) / Jour(s)

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 cat was washed a day after the initial flea and tick shampoo. According to the veterinarian report the cat was treated after the Flea and tick shampoo with Revolution (Selamectin). Than, the symptoms aggravated and started and the cat vomiting the following day. The veterinaran report that the same evening another cat in the houshold was treated with spot on-product (Zodiac). The victim was also treated with this same product the previsou month.The hospitalization was done onto the ground of presumpting diagnosis of toxin exposure. Treatment were IV fluid therapy, pain management and anti-emitic.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Major

19. Provide supplemental information here

The incident is probably caused by the accumulation of the different pest control product used at once onto the cat (victim) and in this household.