Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4261

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-34321082

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.

16-JUL-13

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

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.       PMRA Submission No.       EPA Registration No. 2596-125

Product Name: Ultraguard Plus Flea/ Tick Spray for Dogs

• Active Ingredient(s)
  • TETRACHLORVINPHOS
    • Guarantee/concentration 1.08 %

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7. b) Type of formulation.

Liquid

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

Great Dane

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

110

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

• General
  • Symptom - Vocalizing
  • Symptom - Death
  • Symptom - Pain

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Specify - Hind limbs "not working"

12. How long did the symptoms last?

Persisted until death

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

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

1-34321082 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal spray containing the active ingredient tetrachlorvinphos. The reporter indicated that he applied the spray to his 10 year old, 110 pound, male Great Dane eight days prior to initial contact with the registrant. Seven days after the product was applied the reporter indicated that the dog was reluctant to rise and did not get up to great him when he returned from work. The following day, the dog vocalized when it lifted its head and it would not get up at all; per the reporter the dog was fine in the front legs but the back legs just did not work and the reporter also thought that the dog was experiencing pain in the back legs. The reporter was advised that if the dog was suffering from systemic toxicity generalized symptoms would be expected; not focal symptoms as described. The reporter was further advised to bath his dog with a non-insecticidal shampoo and to seek veterinary care as soon as possible for diagnosis and appropriate treatment of the described symptoms. On follow- up call, three days later, the reporter indicated that his dog passed away on the day of initial contact before veterinary care could be provided. Per the reporter, just prior to the dogs death it was having a hard time breathing, it then took 2 deep breaths and passed away. A necropsy was offered to help determine the cause of death. The reporter initially expressed in an interest in having a necropsy performed but never requested necropsy submission paperwork. 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

Death

19. Provide supplemental information here