Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0634

2. Registrant Information.

Registrant Reference Number: 191956

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.

05-NOV-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 25922      PMRA Submission No.       EPA Registration No.

Product Name: Hartz UltraGuard FleaTick Drops for Dogs and Puppies over 14KG (30lbs

• Active Ingredient(s)
  • PERMETHRIN

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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).

Firstly applied on Oct 22, 2009 and then a week or so later, gave dog bath. Then reapplied on Nov 5, 2009 at 8:30 am. Dog also has Hartz Flea Collar, but not sure which one.

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

Shihtzu

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - scratching

• General
  • Symptom - Abnormal behaviour
  • Specify - acting irractically, not acting like himself, jumping

12. How long did the symptoms last?

Unknown / Inconnu

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

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

After first dosage on Oct 22, 2009, dog jumping, acting irractically, scratching, and not like himself. Dog given bath 1 week later. Product reapplied on Nov 5, 2009 at 8:30 am. Four hours later dog started to show signs. Dog also has Hartz Flea Collar, but unsure which one. Consumer told to remove collar and bath dog with mild dish detergent. Told to bath dog 3 times, to get off product. 25922 is registered on over 30 lb dog, and not on 10 lb dog.

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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

25922 is registered on over 30 lb dog, and not on 10 lb dog.