Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3869

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-23148831

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.

Domestic Animal

4. Date registrant was first informed of the incident.

22-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

21-JUN-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)

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-22

Product Name: UltraGuard Rid Flea Tick Shampoo for Dogs Clean Fresh Scent 18 fl oz

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .149 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .089 %
  • PYRETHRINS
    • Guarantee/concentration .045 %

---

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).

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

toy poodle

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

12

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Anorexia

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

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

1-23148831- The reporter calls to indicate exposure of her animal to a pesticide containing the active ingredients Pyrethrins, Piperonyl butoxide, and N-octyl bicycloheptene dicarboximide. The caller indicates she shampooed her 9 year male Toy poodle dog with the product on two consecutive days. The first time was two days prior to the initial contact with the registrant. The day of the second bath the animal began to demonstrate signs of vomiting and anorexia. The caller was advised on initial contact to seek prompt veterinary care. The reporter spontaneously called back the following day and advised the registrant that the animal had died. She had brought the animal to the veterinarian following the first call to the registrant and had blood work (unspecified) drawn that was reported to have been within normal limits. The veterinarian had given the animal intravenous fluids, antiemetic medication, and sent the animal home. The caller indicates the veterinarian had stated the animal may have had some form of "stomach flu" and did not think the signs demonstrated were due to exposure to the product. It was reported the veterinarian had thought the signs demonstrated were inconsistent with exposure to the active ingredients. She reported the animal had died spontaneously within 4 hours of bringing it home from the veterinarian's office. The caller was told the label instructions for this product did not allow for use of the product on two consecutive days. She acknowledged she had seen this. She was told that despite this deviation from label instructions the symptoms seen would not be expected following use of the product. The caller provided information about registrant supported necropsy to determine the animal's cause of death. It is not known if she availed herself of this service. No further information is available.

---

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here