Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6584

2. Registrant Information.

Registrant Reference Number: 1-35262265

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.

17-OCT-13

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

16-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. 30181      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Plus Flea/Tick Dog Spray with Aloe

• Active Ingredient(s)
  • (S)-METHOPRENE
  • TETRACHLORVINPHOS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin
  • Symptom - Irritated skin

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

Unknown

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

Other

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.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

1-35262265 - The reporter indicated that he was exposed to an insecticidal spray containing the active ingredients tetrachlorvinphos and methoprene. The reporter got some of the product on his hands one day prior to initial contact with the registrant and the following day his hands were irritated. The reporter was advised that direct skin exposure may cause transient irritation treatment with vitamin E or an aloe vera product was recommended. On follow-up call, six days later, the reporter indicated that his hands were getting better but they were still a little irritated and red. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.