Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5603

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27623226

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.

06-OCT-11

5. Location of incident.

Country: UNITED STATES

Prov / State: WEST VIRGINIA

6. Date incident was first observed.

04-OCT-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: UltraGuard Plus Flea Tick Spray for Cats

• 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

5

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Diarrhea

• General
  • Symptom - Dehydration

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

• Gastrointestinal System
  • Symptom - Bloody stool

• Skin
  • Symptom - Pale mucous membrane colour

• General
  • Symptom - Death
  • Symptom - Pain

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

1-27623226-The reporter, a pet owner, indicted her animal had been exposed to an insecticidal product containing the active ingredient tetrachlorvinphos and methoprene. The pet owner indicated she applied the product to her three year five pound female mixed breed three days prior to the initial contact with the registrant. One day later the animal refused food and water and had diarrhea. The next day the pet was reluctant to move, had pale mucus membranes, was dehydrated, painful and had bloody stool. The pet owner had washed the animal but it died later the same night. The pet was not brought to the veterinarian. The animal had been buried without a 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