Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-5797

2. Registrant Information.

Registrant Reference Number: 361283

Registrant Name (Full Legal Name no abbreviations): Hartz Canada Inc.

Address: 1125 Talbot Street.

City: St. Thomas

Prov / State: ON

Country: Canada

Postal Code: N5P 3W7

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

27-AUG-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

16-AUG-13

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: HARTZ 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

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

6.2

lbs

8. Route(s) of exposure

Skin

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Skin
  • Symptom - Burns (superficial)
  • Symptom - Red skin

• General
  • Symptom - Fever

• Gastrointestinal System
  • Symptom - Loss of appetite
  • Symptom - Weight loss

12. How long did the symptoms last?

Unknown / Inconnu

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

Yes

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

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 reporter, a pet owner, on August 13, 2013, put one collar on a male 13 month shaven cat. Less than a week later, the cat was very quiet and and kind of sad, and for several days he was like this. One day the owner picked up him to pet and inspect him and saw a burn just on top of the neck (under the necklace). It was the size of a 5 cents piece. Owner took off the necklace immediately on the 20th of August. Also the cat on August 16th started losing his appetite. The cat was licking his back. The cat had several fevers and stopped eating. He used to weight around 6.2 pounds today he is about 3.8 pounds due to the loss of appetite. Cat taken to the veterinary on August 27th and 29th.

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To be determined by Registrant

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

Moderate

19. Provide supplemental information here