Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1237

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36376963

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.

06-MAR-14

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

06-MAR-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. 26133      PMRA Submission No.       EPA Registration No. 26133

Product Name: UltraGuard Rid Flea/Tick Shampoo for Dogs White Tea

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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.

Other

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

1-36376963-The reporter, a pet owner, indicated that her daughter was exposed to an insecticidal shampoo containing the active ingredients pyrethrins, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The reporter stated that 20 minutes prior to initially contacting the registrant her (age) year old daughter drank about 2 tablespoons of the shampoo and then started coughing. Per the caller her daughter is currently on antibiotics for a previously diagnosed ear and lung infection. Because of the lung infection the patient had a cough prior to the exposure but the reporter thinks that her daughters cough became worse after the exposure. On follow-up call, one day later, the reporter indicated that the cough was still present but her daughter was doing better. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.