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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1603

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36680687

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.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

Unknown

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.

PMRA Registration No. 25226      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuard Flea/Tick Carpet Powder

• Active Ingredient(s)
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

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: Res. - In Home / Rés. - à l'int. maison

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Lesion
  • Specify - Pimples

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?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

Contact with treated area

What was the activity? Daily living

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

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 mos <=6 mos / > 2 mois < = 6 mois

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.)

1-36680687 - The reporter, a home owner, indicated that she was exposed to an insecticidal carpet powder containing the active ingredients phenothrin and n-octyl bicycloheptane dicarboximide. The reporter applied the carpet powder in her home about 3 months prior to initial contact with the company. The powder was vacuumed after application. About 1-2 months prior to her initial call the reporter developed pimples on her chest and on one leg. The reporter was advised that the described symptoms are not consistent with exposure to the product and medical attention was recommended for any persistent symptoms. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.