Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3073

2. Registrant Information.

Registrant Reference Number: PROSAR cases 1-26489622, 1-26491131, 1-26502956

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.

14-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

12-JUN-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. 2596-151

Product Name: UltraGuard Flea Tick Drops for Dogs Puppies Over 60 lbs

• Active Ingredient(s)
  • D-PHENOTHRIN
    • Guarantee/concentration 85.7 %

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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

Siberian Husky

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

80

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

• General
  • Symptom - Death

• Respiratory System
  • Symptom - Coughing up blood

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Respiratory System
  • Symptom - Other
  • Specify - pulmonary contusions
  • Symptom - Pulmonary edema

• General
  • Symptom - Vocalizing

• Nervous and Muscular Systems
  • Symptom - Muscle tremors

• Gastrointestinal System
  • Symptom - Bloody vomit

• Nervous and Muscular Systems
  • Symptom - Seizure

• Respiratory System
  • Symptom - Chest congestion

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?

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

1-26489622, 1-26491131, 1-26502956 The reporter, a pet owner, indicated his animal was exposed to an insecticidal product containing the active ingredient phenothrin. The pet owner had contacted the registrant on three separate occasions not revealing he had called prior. In all circumstances the history provided was divergent. Each interaction will be described independently here. The pet owner described applying the product to his seven year male eighty pound Siberian husky dog either three or four days prior to his initial contact. He indicated he was away from home briefly two days prior to his initial contact and on return home he discovered his animal had vomited. The animal was taken to the emergency veterinarian later the same day because the animal had been coughing or spitting up blood. The animal was brought home again as he could not afford veterinary care. The dog died just prior to his initial contact with the registrant. The pet owner was advised the signs seen were inconsistent with the toxicity profile of the active ingredient. He was advised of registrant supported necropsy to assist in determining the animal¿s cause of death. The pet owner contacted the registrant one separate time three hours later not revealing he had called prior. He provided the following history. The pet owner indicated he applied the product to his seven year eighty pound male Siberian husky dog three or four day prior to his initial contact. He reports he was away from home briefly two days prior to his initial report and when he returned home he noted the animal had vomited was coughing up blood, and was 'walking funny'. The animal was brought to the emergency veterinarian where the animal was found to have pulmonary contusions edema. The veterinarian has done a heartworm test (negative), given 'nausea meds', and 'a couple shots'. The animal continued to have the same signs until the day prior to his initial contact. The morning of his initial contact the animal vocalized, dropped its head and died. The caller indicated the emergency vet is continuing to work the animal up but did not specify tests being done. The pet owner was advised the signs seen were inconsistent with the toxicity profile of the product. He was advised of registrant supported necropsy to assist in determining the animal¿s cause of death. The pet owner contacted the registrant on additional time the same day not revealing he had spoken with the registrant prior. On this occasion he indicated he applied the product to his seven year old eighty pound male Siberian husky dog three days prior to his initial contact with the registrant. He reported one day after application the animal had vocalized, vomited, experienced tremors, was ataxic, and spit or vomited blood. The animal was brought to the emergency veterinarian where they had 'ruled out toxins, rat poison, and antifreeze'. The pet owner stated the animal had died the day of his initial contact due to seizures and lung congestion. The pet owner was advised the signs seen were inconsistent with the toxicity profile of the active ingredient. He was advised of registrant supported necropsy that may assist in determining the animal¿s cause of death. It is unclear which aspect of the varying histories provided by the caller are reliable in this circumstance. 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