Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4187

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-31201498

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.

13-AUG-12

5. Location of incident.

Country: UNITED STATES

Prov / State: WYOMING

6. Date incident was first observed.

03-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. 2596-151

Product Name: UltraGuard Flea/TIck Drops for Dogs and Puppies

• 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Bassett Hound

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

Unknown

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

• Gastrointestinal System
  • Symptom - Salivating excessively

• Nervous and Muscular Systems
  • Symptom - Confusion

• General
  • Symptom - Death
  • Symptom - Dehydration

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

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Vomiting
  • Symptom - Anorexia

• Nervous and Muscular Systems
  • Symptom - Recumbent

• Blood
  • Symptom - Leukocytosis
  • Symptom - Other
  • Specify - Increased hematocrit

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?

2

Day(s) / Jour(s)

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

1-31201498 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticidal product containing the active ingredient phenothrin. The pet owner reported that the product was applied to her 5-year-old, male Basset Hound 11 days prior to initial contact with the registrant. The day after the product was applied the reporter found her dog in the yard drooling and confused. Later that day the dog couldn get up and then it was trembling and was ataxic. The reporter bathed the dog in a non-insecticidal shampoo and brought the dog to her veterinarian that night. The reporter indicated that the veterinarian hospitalized the dog for 2 days on intravenous fluids and blood work was run which showed a high white blood cell count and a high red blood cell count. Two days later the dog was still not himself but he was sent home on oral antibiotics and Rimadyl no diagnosis was given by the veterinarian. Four days prior to initial contact with the registrant the dog had diarrhea and 3 days prior to initial contact the dog stopped eating. The dog vomited once one day prior to initial contact and passed away at home that same night. The reporter was advised that an increased white blood cell count is an indication of an infection and is not consistent with exposure to this product. It was recommended that she discuss the diagnosis with her veterinarian. 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