Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-6269
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-42147769
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.
12-OCT-15
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
12-OCT-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.
PMRA Submission No.
EPA Registration No. 2596-162
Product Name: UltraGuard Plus Flea/Tick Dog Shampoo with Soothing Aloe
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration .27 %
- PYRIPROXYFEN
- Guarantee/concentration .025 %
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Beagle
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
15
7. Weight (provide a range if necessary )
32
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
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
1-42147769 - The reporter, a pet owner, indicated her dog was exposed to a shampoo containing the active ingredients phenothrin and pyriproxyfen. The reporter bathed her 15-year-old, male, 32 pound beagle with the shampoo one day prior to initial contact with the registrant. Immediately after the bath the dog seemed lethargic; he lay down and did not want to get up and then about 10 minutes later he defecated, vomited and died. The reporter was advised that per package labeling the product should only be used in aged animals after consultation with a veterinarian. Aged animals may have unidentified illness and stressful events, such as bathing, may lead to decompensation. A necropsy could help determine the cause for the dogs death but at the time of the call the dog had already been buried. No additional 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