Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-1656

2. Registrant Information.

Registrant Reference Number: L0143098_206823

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

Address: 1125 Talbot Street

City: St. Thomas

Prov / State: ON

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.

30-MAR-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

29-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. 25922      PMRA Submission No.       EPA Registration No.

Product Name: HARTZ ULTRAGUARD FLEA TICK DROPS FOR DOGS 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).

Used product in January-left for 8 days-returned-used product the next month-later noticed dog had irritated skin-there was a lump at the site of application-when touched the skin broke and bled-consumer said the irritation has spread over dogs body-dog taken to vet-vet not sure of reason-said they are not familiar with Hartz product-consumer said she had taken dog to vet several times. Consumer told by Hartz that we would not expect a problem but sensitivity can occur-bathing the product off usually helps-vet can call for further assistance-consumer wanted a call back-she doesn't know what else to do-told Hartz can send letter explaining what happened, upc and copy of vet bill for our review.

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 )

1

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>8 hrs <= 24 hrs / >8 h <= 24 h

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Respiratory System
  • Symptom - Panting

• General
  • Symptom - Fever
  • Specify - running a temperature
  • Symptom - Vocalizing
  • Specify - whining

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?

Unknown

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 called said she applied product to dog last night-this morning the dog is having a reaction-told consumer to give a thorough bath with mild soap, towel dry, give fluids and keep close eye-if anything further-consult vet and vet has any questions to call.

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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

N/A