Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-5312

2. Registrant Information.

Registrant Reference Number: 144730

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

Address: 1125 Talbot Street

City: St. Thomas

Prov / State: Ontario

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.

12-JAN-09

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

11-JAN-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.       PMRA Submission No.       EPA Registration No. 2596-22

Product Name: HARTZ 2 IN 1 RID FLEA DOG SHAMPOO

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

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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).

unknown.

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

N/A

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

15

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• General
  • Symptom - Abnormal behaviour

• Nervous and Muscular Systems
  • Symptom - Aggressive behaviour

• General
  • Symptom - Biting
  • Symptom - Abnormal behaviour
  • Specify - tried to bury herself in snow to remove product
  • Symptom - Hesitancy to move

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?

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

Consumer reports dog had second reaction to product. Dog acting strange, and seems to try to bury in the snow to remove product. Owner baths dog. Dog doing better. In an earlier call product used on Friday. All day Saturday and Sunday dog abnormal. Dog very protective, and bites if anyone comes near. Dog lies in one spot. Then dog recovers. No irritation on skin.

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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

Consumer reports dog had second reaction to product. Dog acting strange, and seems to try to bury in the snow to remove product. Owner baths dog. Dog doing better. In an earlier call product used on Friday. All day Saturday and Sunday dog abnormal. Dog very protective, and bites if anyone comes near. Dog lies in one spot. Then dog recovers. No irritation on skin.