Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-3369

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-37831634

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.

17-JUL-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-JUL-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. 30734      PMRA Submission No.       EPA Registration No.

Product Name: Ultraguard Flea/Tick Treatment for Dogs/ Puppies 14-28 kg

• Active Ingredient(s)
  • D-PHENOTHRIN

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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

Boxer

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.58

7. Weight (provide a range if necessary )

35.2

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Skin
  • Symptom - Hair loss

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

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

1-37831634 - The reporter, a pet owner, indicated that her dog was exposed to a spot-on insecticide containing the active ingredient phenothrin. The reporter applied the product to her 7-month-old, 35.2 pound, female boxer four days prior to initial contact with the registrant. After product application the dog became lethargic, ataxic and had some hair loss. One day prior to initial contact the dog was bathed with a non-insecticidal shampoo and it was taken to the veterinarian where it was given electrolytes in its water but no additional treatment was provided. At the time of the initial call the reporter indicated that the dog was doing better but it was still uncoordinated. On follow-up call, four days later, the reporter indicated that her dog was completely better 5 days after the exposure. 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