Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2722

2. Registrant Information.

Registrant Reference Number: Prosar 1-18920785

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.

Human

4. Date registrant was first informed of the incident.

23-JUN-09

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

23-JUN-09

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: Ultraguard Flea/Tick Collar for Cats (Canada)

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Other

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-18920785: A reporter called on 06/23/2009 to report the exposure of her son to a flea and tick collar containing the active ingredient Tetrachlorvinphos. According to the reporter, the child got some of the powder from the collar on his hands and wiped his eyes about 30 minutes prior to the report. The child developed eye irritation and rinsed his eyes out. At the time of the report, the eye irritation had improved. The reporter was advised that the product may irritate the eyes but is not corrosive or expected to cause corneal burns. A recommendation was made to rinse the eyes for 20 minutes with tepid water. A recommendation was also made to have the child evaluated by a health care professional should his signs persist longer than 6 hours or worsen in severity.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.