Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1621

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-32391709

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.

02-JAN-13

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

23-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. 2596-125

Product Name: Ultraguard Flea and Tick Spray for Dogs

• Active Ingredient(s)
  • TETRACHLORVINPHOS
    • Guarantee/concentration 1.08 %

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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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.16

7. Weight (provide a range if necessary )

2

lbs

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

• Gastrointestinal System
  • Symptom - Vomiting

• General
  • Symptom - Death
  • Symptom - Loss of balance
  • Specify - Wobbly

• Gastrointestinal System
  • Symptom - Bloody vomit

• Respiratory System
  • Symptom - Coughing
  • Specify - Making a hacking sound

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

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

1-32391709 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal product containing the active ingredient tetrachlorvinphos. The pet owner reported that she applied the product to her 11 week old, 2 pound, female Yorkshire terrier mixed breed dog 10 days prior to initial contact with the registrant and about 30 minutes after product application the dog was vomiting and wobbly. Later that same evening the owner noted blood in her dogs vomit and a hacking sound. The caller called the local emergency clinic that night and per the caller the clinic indicated that she should bring her dog to the clinic the following morning. She bathed her dog but the symptoms continued through the night and the following morning the puppy died. The caller was advised that her dog may have had sensitivity to the product. Bathing with a non-insecticidal shampoo was recommended followed with treatment by a veterinarian. Young, small animals are very susceptible to severe symptoms from dehydration when vomiting multiple times. 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