Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-0670

2. Registrant Information.

Registrant Reference Number: 160105-000028

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.

31-DEC-15

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

27-DEC-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)

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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

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

20

Units: mL

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Himalayen

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

6.83

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• General
  • Symptom - Weakness

• Nervous and Muscular Systems
  • Symptom - Trembling

• General
  • Symptom - Malaise

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Symptom - Difficulty walking

12. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 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?

Treatment / Traitement

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Immediately after the bath, the cat had a crisis that lasted 1 min. After the initial crisis, the animal was weak, confused, trembling and had difficulties to walk. These symptoms lasted for 1 hour. The cat fully recovered with no further treatment. The animal was brought to a vetenarian 3 days later (December 30th 2015) for a general examination. The vetenarian reported that it is probable that the animal suffered an undesirable reaction to the Flea and Tick Shampoo and recommended not to use the product on the animal anymore. The vetenarian administered another flea treatment (Advantage).

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To be determined by Registrant

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

Minor

19. Provide supplemental information here