Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3760

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-34140142

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.

27-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

24-JUN-13

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. 25655      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Flea/Tick Spray for Cats

• 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: Res. - In Home / Rés. - à l'int. maison

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?

No

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

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

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-34140142 - The reporter, the patients aunt, indicated that her nephew was exposed to an insecticidal spray containing the active ingredient tetrachlorvinphos. The reporter indicated that three days prior to initial contact with the registrant the product was sprayed all over the home on couches, carpets, etc. The reporters (age)-year-old nephew was in the house during application. No specific exposure was described but that same day the child vomited 15 times. The patient was taken to the doctor where he was given intravenous fluids for the day but the vomiting has persisted through the week and on the day of initial contact the reporter indicated that her nephew had vomited two times. The reporter was advised that the active ingredient in this product is a very low percentage and the described symptoms would not be expected unless the product was directly ingested. On follow-up call, one day later, the reporter indicated that the child was doing a lot better. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.