Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0067

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-28151895

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.

Human

4. Date registrant was first informed of the incident.

21-NOV-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

21-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. 25923      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea Tick Drops for Dogs Puppies Under 30 lbs

• Active Ingredient(s)
  • PERMETHRIN

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7. b) Type of formulation.

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

4. How long did the symptoms last?

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

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-28151895- The reporter indicates she was exposed to an insecticide containing the active ingredient permethrin. The reporter indicates she applied the product, a topical flea and tick preparation for dogs to her pet with 2 hours of her initial report with the registrant and noted within thirty minutes vomiting nausea and dizziness. The pet owner did not indicate direct exposure but indicated an aroma to the product was bothersome to her. The reporter was indicated the fragrance of pesticides can sometimes be irritating to sensitive individuals. She was advised effective ways to remove the product from her animal and ventilate. On follow up one day later she indicated her symptoms had spontaneously resolved by the next morning. There was no need to see a doctor. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.