Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-3793
2. Registrant Information.
Registrant Reference Number: ProPharma Group case#: 1-44671715
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.
30-JUN-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
Unknown
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. 30181
PMRA Submission No.
EPA Registration No.
Product Name: HARTZ ULTRAGUARD PLUS FLEA & TICK SPRAY FOR DOGS WITH ALOE
- Active Ingredient(s)
- (S)-METHOPRENE
- TETRACHLORVINPHOS
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
80
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Skin
- Symptom - Hair loss
- Symptom - Irritated skin
12. How long did the symptoms last?
Unknown / Inconnu
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
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
1-44671715 - The reporter, a pet owner, indicated her dog was exposed to an insecticidal spray containing the active ingredients Tetrachlorvinphos and (S)-methoprene. The reporter applied the product to her 7-year-old, 80-pound, female mixed breed dog approximately three weeks before initial contact with the registrant. The reporter stated that the dog developed hair loss and irritation at the application site at an unknown time. The reporter was not available for medical advice on the day of initial contact. On follow-up call five days later, the reporter indicated she had taken the dog to a veterinarian who prescribed medication and the dog is doing fine now. 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
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.83
7. Weight (provide a range if necessary )
50
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Skin
- Symptom - Hair loss
- Symptom - Irritated skin
12. How long did the symptoms last?
Unknown / Inconnu
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
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
1-44671715 - The reporter, a pet owner, indicated her dog was exposed to an insecticidal spray containing the active ingredients Tetrachlorvinphos and (S)-methoprene. The reporter applied the product to her 10-month-old, 50-pound, female mixed breed dog approximately three weeks before initial contact with the registrant. The reporter stated that the dog developed hair loss and irritation at the application site at an unknown time. The reporter was not available for medical advice on the day of initial contact. On follow-up call five days later, the reporter indicated she had taken the dog to a veterinarian who prescribed medication and the dog is doing fine now. 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