Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-5571

2. Registrant Information.

Registrant Reference Number: 1-34814993

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.

03-SEP-13

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

26-AUG-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.       PMRA Submission No.       EPA Registration No. 2596-150

Product Name: UltraGuard Plus Flea/Tick Drops Plus for Dogs/Puppies 16-30 lbs

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration 2.3 %
  • 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

Sheltie

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

20

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 - Anorexia
  • Symptom - Vomiting

• General
  • Symptom - Lethargy

• Blood
  • Symptom - Anemia

• Respiratory System
  • Symptom - Difficulty Breathing

• General
  • Symptom - Death

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

1-34814993 - The reporter, a pet owner, indicated that her dog was exposed to an insecticidal spot-on product containing the active ingredients phenothrin and methoprene. The reporter indicated that she applied this product to her 5 year old, 20 pound, female Shetland sheepdog 8 days prior to initial contact with the registrant. Three days after product application the reporter brought her dog the veterinarian because it was lethargic and not eating or drinking much. On physical exam the veterinarian noted that the dog was pale and indicated to the reporter that the dog was anemic likely secondary to a large flea burden. The dog was treated with an oral insecticide and sent home. The reporter brought the dog back to the clinic the next day as it was not getting better. Per the reporter the veterinarian gave a shot for anemia and sent the dog home. That night the owner noted the dog was breathing funny, it then took one large breath and passed away. A necropsy was recommended to help determine a cause for death but it was declined by the pet owner. 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