Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4294

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-38262854

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.

27-AUG-14

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

26-AUG-14

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. 2596-167

Product Name: Ultraguard Flea/Tick Prevention for Dogs/Puppies 61-150 lbs

• Active Ingredient(s)
  • ETOFENPROX
    • Guarantee/concentration 55 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 1 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 10 %

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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

German Shepherd

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

72

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Trembling

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Symptom - Difficulty getting up

12. How long did the symptoms last?

Persisted until death

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

1

Day(s) / Jour(s)

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

1-38262854 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticide containing the active ingredients etofenprox, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The reporter applied the product to her 4 year old, 72 pound female German Shepherd (Subform III #1) and to her 5-year-old, 82 pound, male German Shepherd one day prior to initial contact with the registrant. At the time of the initial call the reporter indicated that her female dog was shaking, having trouble getting up and having trouble walking. The reporters male dog was shaking and having trouble walking. The reporter had used this product on both of her dogs without issue. On follow-up call, one day later, the reporter indicated that she brought her dogs to the veterinarian on the day she contacted the registrant and both dogs stayed overnight at the clinic. That evening the clinic told her that both dogs were stable but the following morning she was told that her female dog had passed away. Her male dog was still stable. A necropsy was recommended to determine an underlying cause for the females dog death but it was declined. 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