Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2917

2. Registrant Information.

Registrant Reference Number: PROSAR case # 1-22597677

Registrant Name (Full Legal Name no abbreviations): The Hartz Mountain Corporation

Address: 400 Plaza Drive

City: Secaucus

Prov / State: NJ

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.

12-MAY-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

10-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.       PMRA Submission No.       EPA Registration No. 2596-125

Product Name: Hartz UltraGuard Flea Tick Spray for Dogs

• Active Ingredient(s)
  • TETRACHLORVINPHOS
    • Guarantee/concentration 1.08 %

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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 caller specifies she sprayed her animal and rubbed him. No other information regarding application was provided.

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

Mixed breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.58

7. Weight (provide a range if necessary )

30

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Fasciculations
  • Symptom - Rigidity

• 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

1-22597677: The reporter, an animal owner, called on 05/12/10 to report exposure of her 7 month mixed breed dog to a pesticide containing the active ingredient Tetrachlorvinphos. The caller reported she had been using the product chronically on her animal for the past 4-5 months. She reported she had used 2.5 containers of the product on her animal in that time. She had been using the product as frequently as daily when fleas or ticks were observed on the animal. She reported she sprayed the product on her animal the evening of 05/10/10. She reported immediately the animal demonstrated fasiculations and rigidity. The animal refused food and drink and when she forced water the animal vomited. The symptoms were reported to persist until death the following morning. The owner did not seek veterinary care and no necropsy had been performed. The caller was informed that the product is well tolerated when used according to label instructions and offered assistance with necropsy to determine the cause of the animal¿s death. She did not pursue the necropsy. No other information is available.

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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