Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2244

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25945345

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-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: KANSAS

6. Date incident was first observed.

21-APR-11

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. 2596-22

Product Name: UltraGuard Rid Flea Dog Shampoo

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

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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).

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

Rat terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom - Vomiting

• Blood
  • Symptom - Coagulopathy
  • Symptom - Hypokalemia

• 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

1-25945345- The reporter, a veterinarian, indicates a patient presented to her which was reported to have been exposed to an insecticidal shampoo containing the active ingredients pyrethrins, piperonyl butoxide, and N-octyl bicycloheptene dicarboximide. The veterinarian indicated the patient, a three year male Rat terrier dog, had the product applied to it the night prior to her initial contact with the registrant. The pet owner had indicated the animal had licked some of the product off of its coat while being bathed. The pet owner had stated the animal had a seizure during the night but the veterinarian was unsure when. The pet was brought to the veterinarian in the morning where it was treated with injectable diazepam and a CBC/coagulation profile was run. The CBC was reported to be within normal limits but the activated clotting time was in excess of 10 minutes. No other signs were observed but the animal had died just prior to the initial report. The veterinarian was advised the signs seen were inconsistent with the toxicity profile of the active ingredient. The veterinarian was advise of a registrant supported necropsy program that could assist in determining the animals cause of death. It is unknown if the veterinarian was able to obtain the owners permission to proceed with the necropsy. No further 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