Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-1435

2. Registrant Information.

Registrant Reference Number: PROSAR 1-21858972

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.

08-MAR-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

05-MAR-10

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. 24650      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Plus Flea/Tick Spray for Dogs (Canada)

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

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PMRA Registration No. 25226      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea/TIck Carpet Powder (Canada) 2

• Active Ingredient(s)
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

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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: Personal use / Usage personnel

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

The powder was applied to the furniture on 03/05/2010. The spray was applied to the reporter's hair on 03/05/2010. NOTE: The spray is not labeled for use on humans. The reporter also took Oxycontin on 03/05/2010 just prior to her use of the product.

To be determined by Registrant

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

No

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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash
  • Symptom - Itchy skin

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Chemical taste in mouth
  • Specify - "Tastes product in her mouth"

• Nervous and Muscular Systems
  • Symptom - Hallucination

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)

Application

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-21858972: A reporter called on 03/08/2010 to report her exposure to a flea and tick carpet powder containing the active ingredients Phenothrin and NOBD, and to a flea and tick spray containing the active ingredients Methoprene, Pyrethrins, NOBD, and Piperonyl Butoxide. According to the reporter, she took oxycontin for chronic pain issues on 03/05/2010. After taking the medication, she started having hallucinations and thought she had fleas. She applied the powder on her furniture and applied the spray to her hair. She sat on the furniture before she vacuumed the powder off of it and did not shower for 2 days. At the time of the report, the reporter had an itchy rash on the middle part of her back, a headache, and the taste of the product in her mouth. The reporter was advised that both products have a wide safety margin and a low level of toxicity. Absorption and systemic toxicity would not be expected following the exposure described. Prolonged dermal contact may result in skin irritation or rash. A recommendation was made to use a topical hydrocortisone cream to relieve the signs. It was also recommended that the caller vacuum thoroughly to remove the product. The reporter was advised that headache and persistent unpleasant taste are not anticipated without lingering product odor. A recommendation was made to consult a health care provider about the signs and the experience with the medication. Multiple attempts at follow up were unsuccessful. No further information was obtained. NOTE: The spray is not labeled for use on humans.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.