Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4178

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-31126256

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-AUG-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MAINE

6. Date incident was first observed.

02-AUG-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. 2596-150

Product Name: UltraGuard Plus Flea and Tick Drops Plus for Dogs/Puppies 4-15 lbs

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration 2.3 %
  • 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.

1.1

Units: mL

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

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

8.6

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

• Nervous and Muscular Systems
  • Symptom - Ataxia
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Bloody stool

• 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?

Yes

14. b) How long was the animal hospitalized?

Unknown

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

1-31126256 - The reporter, a pet owner, indicated that her dog was exposed to an insecticidal product containing the active ingredients phenothrin and methoprene. The pet owner reported that the product was applied to her 6-year-old, female, Chihuahua five days prior to initial contact with the registrant. The day after application the reporter indicated that her dog was ataxic. The reporter bathed her dog that day using dawn dish soap and brought her to her veterinarian. The veterinarian informed the reporter that the dog had impacted anal glands; the dog was treated with fluids and sent home on oral Metacam, which the reporter gave for 3 days. Three days later the reporter indicated that the dog still couldnt walk and that evening the dog had three seizures. The dog was brought to an emergency clinic that night but was sent home that same night with no treatment. The next day, the day of initial contact with the registrant, the dog had 2 seizures and severe bloody diarrhea. The dog was brought back to the veterinarian and she was hospitalized on intravenous fluids. The veterinarian was advised that the symptoms and time line are somewhat inconsistent with product exposure and a complete work-up was recommended to determine an underlying cause for the dogs illness. Bathing the animal was recommended to assure full decontamination and continued symptomatic and supportive care was advised including the use of barbiturates for seizure control. On follow-up, two days later, the reporter indicated that her dog had died on her own yesterday at the veterinary clinic. The possibility of performing a necropsy was discussed with the pet owner but the pet owner was not interested. 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