Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2650

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26157411

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.

16-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

14-MAY-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. 2596-140

Product Name: HARTZ ULTRA GUARD PLUS FLEA & TICK FOR DOGS

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .07 %
  • 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).

To be determined by Registrant

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

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

14

7. Weight (provide a range if necessary )

7

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Diarrhea
  • Symptom - Bloody stool

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

• 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

1-26157411- The reporter, a pet owner, indicates his animal was exposed to an insecticidal product containing the active ingredients tetrachlorvinphos and methoprene. The pet owner indicates he applied the product to his fourteen year seven pound female Chihuahua two days prior to his initial contact with the registrant. The reporter indicates he applied the flea and tick spray to his animal at seven pm and the animal immediately rolled on the carpeting according to the owner in effort to remove it from the coat. By ten pm that evening the animal exhibited the signs of vomiting, diarrhea and bloody stool. The pet owner indicates by the next morning the animal was unable to stand. The animal had died two pm that day. The pet owner did not indicate the animal had been brought to the veterinarian or any treatment had been offered. The pet owner was advised that the product carried labeling discouraging use on elderly animals. Despite the product misuse the signs seen and outcome seen would not be expected. The pet owner was advised it was likely that something else was affecting the animal¿s health and necropsy may be helpful in discovering the cause of death. The pet owner indicated the animal had been buried at the time of his initial contact. 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