Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2350

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-30114018

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.

15-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSISSIPPI

6. Date incident was first observed.

12-MAY-12

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 and Tick Drops for Dogs and 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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.5

7. Weight (provide a range if necessary )

12

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
  • Symptom - Diarrhea
  • Symptom - Bloody stool

• Nervous and Muscular Systems
  • Symptom - Muscle tremors
  • Symptom - Shaking

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Seizure

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

1-30114018- The reporter, a veterinarian, reports and animal had presented that had been exposed to an insecticide containing the active ingredient phenothrin. The veterinarian reports the pet owner had applied a flea and tick topical product labeled for dogs 31-60 pounds to her five month female 12 pound mixed breed dog 2-3 days prior to the initial contact. The animal was vomiting, shaking, had muscle tremors, diarrhea, and bloody stool. The reporter had bathed the animal and done both a parvo and intestinal parasite screen, both of which were negative. The veterinarian was advised of the standards of care associated with pyrethroid overdosage in domestic animals. On follow-up the reporter indicated the animal had developed seizures and died at home after she had discharged it. No necropsy had 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