Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0530

2. Registrant Information.

Registrant Reference Number: 2021-CA-000287

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.

19-OCT-21

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

19-OCT-21

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. 2596-168

Product Name: Hartz UltraGuard Dual Action Topical Flea and Tick Prevention for Dogs

• Active Ingredient(s)
  • ETOFENPROX
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PIPERONYL BUTOXIDE
  • PYRIPROXYFEN

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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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Bulldog

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.75

7. Weight (provide a range if necessary )

14.97

kg

8. Route(s) of exposure

Skin

Oral

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

• Nervous and Muscular Systems
  • Symptom - Confusion

• General
  • Symptom - Abnormal behaviour

• Cardiovascular System
  • Symptom - Tachycardia

• Respiratory System
  • Symptom - Panting

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify Treatment and accidental ingestion

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

On 18-Oct-2021, a 0.75 year old, 14.97 kilogram, intact, male, Bulldog dog, in unknown condition, with no known concomitant medical condition, was administered one dose of Hartz UltraGuard Dual Action Topical Flea and Tick Prevention for Dogs and Puppies 15-30lb (Etofenprox / N-Octyl-Bicycloheptene Dicarboximide (MGK-264) / Piperonyl Butoxide / Pyriproxifen (Nylar)), via the topical route by the animal owner. On 19-Oct-2021 the dog got a hold of the box with the remaining product and ingested an unknown amount of the product (one tube was chewed on and another was missing). This was an extra label use as the product is not intended for consumption. Approximately 8 hours post exposure, the dog exhibited confusion and unspecified abnormal behaviour. Veterinary evaluation was recommended. Approximately 9 hours post exposure, the dog was evaluated by a veterinarian and found to be panting and tachycardic, but mentally appropriate. It is unknown if any treatments were performed. Decontamination and supportive care were discussed with the veterinarian. No further information was received.

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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

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and cannot form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.