Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-5431

2. Registrant Information.

Registrant Reference Number: Prosar 1-20673798

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.

07-NOV-09

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

05-NOV-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: UltraGuard Rid Flea/Tick Shampoo for Dogs Clean Fresh Scent 18 fl oz

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .149 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .089 %
  • PYRETHRINS
    • Guarantee/concentration .045 %

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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).

The product was applied to the dog on 11/05/2009.

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

Chihuahua

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.5

7. Weight (provide a range if necessary )

3

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

• Gastrointestinal System
  • Symptom - Drooling
  • Symptom - Loss of appetite
  • Symptom - Vomiting

• General
  • Symptom - Other
  • Specify - "turned sad"

• Gastrointestinal System
  • Symptom - Stomach pain
  • Symptom - Constipation

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

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

1-20673798: A reporter (dog owner) called on 11/07/2009 to report via an interpreter the exposure of her dog to a flea and tick shampoo containing the active ingredients Pyrethrins, Piperonyl butoxide, and NOBD. According to the reporter, the dog was shampooed with the product on 11/05/2009. The reporter initially stated that the dog developed salivation, vomiting, and loss of appetite while still in the bathtub. She later reported that the signs did not develop until several hours later. Additionally, the dog "turned sad", developed abdominal pain, and could not have a bowel movement. The reporter found the dog dead on 11/07/2009. The reporter was advised that the signs described are not expected following routine use of the product. A recommendation was made to consider necropsy to determine the cause of death. No further information was obtained.

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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