Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6278

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-42303116

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.

28-OCT-15

5. Location of incident.

Country: UNITED STATES

Prov / State: SOUTH CAROLINA

6. Date incident was first observed.

20-OCT-15

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. 2596-78

Product Name: UltraGuard Flea/Tick Powder for Cats

• Active Ingredient(s)
  • TETRACHLORVINPHOS
    • Guarantee/concentration 3.3 %

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7. b) Type of formulation.

Dust

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

Colourpoint Shorthair

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.5

7. Weight (provide a range if necessary )

9.6

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death
  • Symptom - Lethargy
  • Symptom - Dehydration
  • Symptom - Hypothermia

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Stiffness

• General
  • Symptom - Hiding

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?

Unknown

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

1-42303116 - The reporter, a veterinarian, indicated that a cat was exposed to an insecticidal powder containing the active ingredient tetrachlorvinphos. The pet owner applied the product to his 1.5-year-old, male cat 8 days prior to initial contact with the registrant. After the product was applied the cat disappeared and was found one day prior to initial contact inside a chair with vomit nearby. The cat felt cold, was lethargic and stiff and was taken to the veterinarian later that night. On exam the cat was very dehydrated with a normal heart rate. The cat was treated with methocarbamol and IV fluids but it died later that same night. A necropsy was recommended to help determine the underlying cause for the animals death. No additional 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