Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3174

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-33643009

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-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

Unknown

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. 25620      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Flea/Tick Collar for Large Dogs (Canada)

• Active Ingredient(s)
  • TETRACHLORVINPHOS

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7. b) Type of formulation.

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

Border Collie

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.46

7. Weight (provide a range if necessary )

27.5

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Diarrhea
  • Symptom - Salivating excessively

• General
  • Symptom - Malaise

• Gastrointestinal System
  • Symptom - Anorexia

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

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

1-33643009 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal collar containing the active ingredient tetrachlorvinphos. The reporter indicated that he applied the collar to his 5.5 month old, 27.5 pound, female Border collie approximately one week prior to initial contact with the registrant. Sometime after the collar was placed, the reporter is unable to specify exactly when, the dog suffered from vomiting, 5-6 episodes of diarrhea, drooling and inappetance. The collar was removed three days prior to initial contact and the dog was bathed in a non-insecticidal animal shampoo. The last vomiting episode was two days prior to initial contact and one day prior to initial contact the stool seemed to be firming up. At the time of initial contact the dog was outside playing and her energy level was normal but per the reporter she was still not herself. The reporter was advised that animals with sensitivity to the product may develop the described symptoms but typically these symptoms would only be expected if the dog suffered from an overdose by ingestion of the collar or inappropriate application. The reporter was further advised that there are numerous possible causes for gastrointestinal upset and he should seek veterinary care for a diagnosis and appropriate treatment. The reporter could not be reached on follow-up. 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

Minor

19. Provide supplemental information here