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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1672

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-25309680

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.

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

Unknown

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.

PMRA Registration No. 25621      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea Tick Collar for Cats Kittens

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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).

To be determined by Registrant

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

Unknown

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

• Skin
  • Symptom - Pruritus

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)

Contact with treated area

What was the activity? residing with a cat to which the product had been applied

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.

Unknown

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.)

1-25309680- The reporter had indicated potential exposure to an insecticide containing the active ingredient tetrachlorvinphos. The reporter indicated the product, a flea and tick collar, had been applied to their companion animal (a cat) some indeterminate time preceding the initial contact with the registrant. The reporter indicates an adult male (human) in the home had developed total body pruritis at some indeterminate time preceding the call. No discreet exposure was described. The reporter asks if itch would be expected when residing in a home shared with an animal to which the product had been applied. The caller was advised the symptoms seen would not be expected but were more consistent with a hypersensitivity response to some unknown antigen in the immediate environment. Avoidance of the product was recommended until the offending antigen could be identified. The caller was advised of OTC symptomatic care and it was recommended they follow up with a physician to determine the cause of the reaction. The reporter did not respond to follow up attempts. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.