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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0186

2. Registrant Information.

Registrant Reference Number: 161208-000063

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.

08-DEC-16

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

08-OCT-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. 28113      PMRA Submission No.       EPA Registration No.

Product Name: Sergeants PreTect Squeeze on Flea Tick Control for Dogs

  • Active Ingredient(s)
    • PERMETHRIN
    • PYRIPROXYFEN

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1.5

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Bichon

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

8.1

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

  • Nervous and Muscular Systems
    • Symptom - Convulsions

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Unknown/Inconnu

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

The first application of the Sergeants flea and tick product was on October 8th. That same day, the dogs convulsed 5 minutes. There was a second dose applied on the back 3 weeks later. The dog may have been able to lick his back after applying. Since October 8, there have been 6 episodes of convulsions that lasted between 5 and 10 minutes. The convulsions took place on these dates: 8 October, 21 October, 13 November, 20 November, 29 November, 6 December.


To be determined by Registrant

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

Moderate

19. Provide supplemental information here