Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-0547

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-32299040

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.

17-DEC-12

5. Location of incident.

Country: UNITED STATES

Prov / State: KENTUCKY

6. Date incident was first observed.

10-DEC-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. 2596-22

Product Name: Ultraguard Rid Flea/Tick Shampoo for Cats

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .149 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .089 %
  • PYRETHRINS
    • Guarantee/concentration .045 %

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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

Cat / Chat

3. Breed

Himalayan

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2

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

<=30 min / <=30 min

11. List all symptoms

System

• Respiratory System
  • Symptom - Difficulty Breathing

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Ataxia
  • Symptom - Difficulty getting up

• Gastrointestinal System
  • Symptom - Fecal incontinence

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

1-32299040 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal shampoo containing the active ingredients pyrethrins, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The pet owner reported shampooing her 2-year-old, female Himalayan cat with the product ten days prior to initial contact with the registrant. Within a few minutes of product application the cat began gasping for air and couldnt walk. The cat was placed on the ground and she continued to have trouble breathing, she could not get up and she lost control of her bowels. She was brought to the veterinarian where x-rays were taken and oxygen was given. The cat responded to the oxygen so transport to a cat specialist was recommended but the cat died en route to the specialist. The reporter was advised that the described symptoms are not expected from product exposure. A necropsy was discussed to help determine an underlying cause for the cats death but the cat had already been buried. 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