Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3917

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26741486

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.

06-JUL-11

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)

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PMRA Registration No. 25621      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea Tick Collar for Cats Kittens

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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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

Shih Tzu

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

15

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 - Other
  • Specify - reverse sneezing
  • Symptom - Sneezing
  • Symptom - Difficulty Breathing

12. How long did the symptoms last?

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

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

Unknown

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

1-26741486- The reporter, a pet owner, indicated her animal was exposed to an insecticide containing the active ingredient tetrachlorvinphos. The pet owner indicated she had first placed the product, a flea and tick collar, on her two year fifteen pound male Shih Tzu dog three or four weeks prior to the initial contact with the registrant. The pet owner reports she noted the caller had fallen off earlier in the day prior tot the call. She later replaced the color on the animal and took it for a walk. The pet reports when she returned home from the walk the animal experienced difficulty breathing and the collar was removed. The signs resolved. The pet owner was advised the signs seen were inconsistent with the toxicity profile of the active ingredient. On follow up the pet owner indicated the difficulty the animal had occurred of and on for fifteen hours. The sign was characterized as reverse sneezing a phenomenon seen in brachycephalic dogs associated with nasopharyngeal irritation. The pet owner indicated the animal eventually sneezed out a blade of grass and was from that point asymptomatic. No further information is available.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here