Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6338

2. Registrant Information.

Registrant Reference Number: 1-35198945

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.

09-OCT-13

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

09-OCT-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. 16673      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea/Tick Powder for Dogs

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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Nausea

• General
  • Symptom - Sweating

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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)

Application

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.

Skin

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.)

1-35198945 - The reporter indicated that he was exposed to an insecticidal powder containing the active ingredient tetrachlorvinphos. The reporter applied the powder to his dog three or four days prior to initial contact with the registrant and during application the reporter used his bare hands to rub the powder into his dogs fur. Later that night the reporter indicated that he had diarrhea, was nauseous, had a headache and was sweating. The reporter was advised that given the low concentration of active ingredient in this product and the low order of toxicity of this organophosphate the described symptoms would not be expected after dermal contact with the product. Medical attention was recommended to determine an underlying cause for the patient's symptoms and appropriate treatment. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.