Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2674
2. Registrant Information.
Registrant Reference Number: ProPharma Group case: 1-43830141
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.
19-APR-16
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
18-APR-16
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. 2596-151
Product Name: HARTZ ULTRAGUARD FLEA & TICK TREATMENT FOR DOGS AND PUPPIES WEIGHING G
- Active Ingredient(s)
- D-PHENOTHRIN
- Guarantee/concentration 85.7 %
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Golden Retriever
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
13
7. Weight (provide a range if necessary )
85
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
- Respiratory System
- Symptom - Respiratory distress
- General
- Symptom - Lethargy
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
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
1-43830141 - The reporter, a veterinarian, indicated a dog was exposed to an insecticidal spot-on product containing the active ingredient D-phenothrin. The reporters client applied the product to his 13-year-old, 85 pound, Golden Retriever female dog one day prior to initial contact with the registrant. On the day the product was applied, the reporters client noted the pet was lethargic and had difficulty breathing. The dog was brought into the reporter for treatment on the day of the initial contact. The reporter was advised to bathe the dog and treat symptomatically. The reporter was informed of the necropsy policy. On follow-up one day later, the reporter stated the dog had died and the death had nothing to do with the product. 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