Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2903

2. Registrant Information.

Registrant Reference Number: 1-22536520

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.

Human

4. Date registrant was first informed of the incident.

07-MAY-10

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

04-MAY-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. 28355      PMRA Submission No.       EPA Registration No.

Product Name: HARTZ ULTRAGUARD REFLECTIVE FLEA TICK COLLAR FOR DOGS PUPPIES

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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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).

N/A

To be determined by Registrant

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

Yes

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: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Swollen eye

• Skin
  • Symptom - Other
  • Specify - looked like chemical burn

• General
  • Symptom - Swelling
  • Specify - arm swollen

• Skin
  • Symptom - Rash
  • Specify - raised bumps

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

Amount of time between application and contact 1

Day(s) / Jour(s)

What was the activity? contact with dog collar

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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.)

Caller applied collar on 5/2 and dog jumped on bed with owners 5/3 am. Both caller and wife came in contact with collar. On 5/4 caller developed swollen eyes. On 5/5 his right arm became swollen and he states it looked like a chemical burn. He had a lot of tiny bumps. Collar removed 5/6 and his symptoms greatly removed. Washed affected areas well with cold water. Now better.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

N/A

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Swollen eye

• Ear
  • Symptom - Other
  • Specify - swollen

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

Amount of time between application and contact 1

Day(s) / Jour(s)

What was the activity? contact with dog collar

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

Eye

11. What was the length of exposure?

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

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.)

Caller applied collar on 5/2 and dog jumped on bed with owners 5/3 am. Both caller and wife came in contact with collar. She had swollen ears and eyes. Washed affected areas well with cold water. Now better.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

N/A