Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0499

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-36090730

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.

30-JAN-14

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

28-JAN-14

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 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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

11

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Skin
  • Symptom - Red skin
  • Symptom - Lesion
  • Specify - Scabs
  • Symptom - Bleeding
  • Symptom - Itchy skin

12. How long did the symptoms last?

Unknown / Inconnu

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

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

1-36090730 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal collar containing the active ingredient tetrachlorvinphos. The reporter stated that he placed the collar on his 4 year old, 11 pound, female mixed breed dog four days prior to initial contact with the registrant. Two days after the collar was applied the pet owner noticed that the skin around the dogs neck was red, had scabs, was bleeding and the dog was scratching the area. The reporter removed the collar and called his veterinarian who told him to apply diaper cream to the affected area. On follow-up call, four days later, the reporter stated that the skin issues had spread and now the dogs entire body was affected. The reporter had taken his dog to the veterinarian for treatment (the reporter did not describe the treatment provided) and he was requesting reimbursement for the veterinary bill. 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

Moderate

19. Provide supplemental information here