Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0063

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-28083237

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-NOV-11

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

11-NOV-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 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Pomeranian

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

20

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

• Nervous and Muscular Systems
  • Symptom - Seizure
  • Symptom - Muscle weakness

• Gastrointestinal System
  • Symptom - Anorexia

• 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?

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

1-28083237- The reporter, a pet owner, indicated her animal was exposed to an insecticidal product with the active ingredients tetrachlorvinphos and methoprene. The reporter described application of the product to her twelve year twenty pound male Pomeranian dog five days prior to her initial contact with the registrant. The pet owner indicated the animal developed the signs of collapse and seizure while on a walk two days after application. The pet owner described difficulty walking, loss of appetite and several more seizures. The pet was bathed with a noninsecticidal shampoo that same day and was the next day taken to the veterinarian. The veterinarian according to the pet owner gave an injection and an oral medication to go home. The pet owner was unable to name the medications given. The pet died four days after application. The animals remains had been submitted for cremation without a necropsy having been performed. 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