Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4186

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-31204656

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.

13-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-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. 25621      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Flea/Tick Collar for Cats/Kittens (purple)

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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.

Other

2. Demographic information of data subject

Sex: Female

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Other
  • Specify - Unpleasant taste

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 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)

Poisoning from ingestion of the pesticide

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

10. Route(s) of exposure.

Oral

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.)

1-31204656 - The reporter, a parent, indicated that her daughter was exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The reporter indicated that ten minutes prior to initial contact with the registrant her (age) daughter used her teeth to take out a staple from the product package. Her daughter immediately had a bad taste in her mouth and within 10 minutes she was feeling nauseous. The reporter was advised that no serious health effects would be expected from the described exposure but nausea can develop from a bad taste. On follow-up, three days later, the parent indicated that her daughters symptoms resolved within an hour. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.