Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4581

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27038193

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.

03-AUG-11

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

01-AUG-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 Refreshing Fresh Citrus

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

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2596-151

Product Name: UltraGuard Flea Tick Drops for Dogs Puppies 31-60 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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Rottweiler

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

42

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

• 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

1-27038193- The reporter, a pet owner, indicates his animal was exposed to two insecticidal products. The first contains the active ingredients pyrethrins, piperonyl butoxide, and n-octyl bicycloheptene dicarboximide, the second contains phenothrin. The pet owner indicated he applied the two products to his one year male forty two Rottweiler dog one day prior to the initial contact with the registrant. The pet owner indicated he had purchased the dog two days prior from a friend. The pet owner indicated he left the animal at home following application. When he returned later the same day he found the animal dead. The pet owner was advised the labeling discourages use of these products at the same time on one animal. Despite the misuse the products would not be expected to yield the outcome seen. 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