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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-2325

2. Registrant Information.

Registrant Reference Number: 2019-US-028837

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.


5. Location of incident.


Prov / State: OREGON

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-177

Product Name: Hartz Ultraguard Pro Triple Active Flea and Tick Shampoo for Dogs

  • Active Ingredient(s)
      • Guarantee/concentration .04 %
      • Guarantee/concentration .27 %
      • Guarantee/concentration .075 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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).

Please refer to field 13 on Subform II or field 17 of Subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Vomiting
    • Symptom - Anorexia
    • Symptom - Weight loss
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

On approximately 04-Oct-2019, a 14 year old, 45 pound, neutered, male, Beagle dog, in unknown condition, with unknown concomitant medical condition, was administered 1 dose of Hartz Ultraguard Pro Triple Active Flea and Tick Shampoo for Dogs (Methoprene / Phenothrin / Pyriproxifen) via the topical route by the animal owner. On approximately 05-Oct-2019, the dog exhibited brown colored, liquid vomit and anorexia. On approximately 06-Oct-2019, the dog exhibited weight loss. On 14-Oct-2019, the dog died at home and was buried. The dog was not evaluated by a veterinarian and no treatments were performed. No further information was received in this case.

To be determined by Registrant

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


19. Provide supplemental information here

Assessment: The active ingredients in this product have a wide margin of safety in dogs and are present in low concentration. Mild GI upset may occur if a dog is able to ingest the product but signs of the severity and duration reported in this case are not expected. Other causes must be considered in this case including underlying cancer, organ failure, infectious disease, and GI foreign body obstruction. No veterinary care was sought so the cause of death remains unknown but it is unlikely to be related to product use. The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and cannot form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.