Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2435
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-40533973
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.
09-MAY-15
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
09-MAY-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. 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?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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 )
0.5
7. Weight (provide a range if necessary )
35
lbs
8. Route(s) of exposure
Oral
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
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.
No
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-40533973 - The reporter, a pet owner, indicated that her dog was exposed to an insecticidal spot-on product containing the active ingredient phenothrin. The reporter stated that just prior to her call she had left her home for 3 hours and sometime during that time period her 6 month-old, female, 35 pound mixed breed dog gained access to the container and bit into one applicator. There was one pile of vomit on the floor when the reporter returned home. On follow-up call, two days later, the reporter indicated that the symptoms had completely resolved by the next day. No additional 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