Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-2673
2. Registrant Information.
Registrant Reference Number: 2020-CA-000357
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.
Human
4. Date registrant was first informed of the incident.
30-SEP-20
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
11-SEP-20
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. 30732
PMRA Submission No.
EPA Registration No.
Product Name: Hartz UltraGuard Flea and Tick Drops for Dogs 2.5 - 6 kg Spot-on
- 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).
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?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
4. How long did the symptoms last?
<=30 min / <=30 min
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
On 11-Sep-2020, a 63 year old, 140 pound, female, human with no known medical conditions, was exposed via the inhalation route, to 1 tube of Hartz UltraGuard Flea and Tick Drops for Dogs 2.5 - 6 kg (Phenothrin (Sumithrin)) while applying the product to her dog. Approximately 10 minutes later, she experienced a headache and nausea. She then went outside for fresh air ventilation and the symptoms resolved after 30 minutes. Approximately 4 hours later, she bathed the product off her dog. No further information was received.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
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.