Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4296

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-38217035

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.

22-AUG-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

16-AUG-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.       PMRA Submission No.       EPA Registration No. 2596-139

Product Name: UltraGuard Plus Flea & Tick Collar for Cats & Kittens (non-specific)

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration 1.02 %
  • TETRACHLORVINPHOS
    • Guarantee/concentration 14.5 %

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7. b) Type of formulation.

Other (specify)

Impregnated collar

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

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

Unknown

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

• Nervous and Muscular Systems
  • Symptom - Ataxia

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Difficulty walking

• General
  • Symptom - Lethargy

12. How long did the symptoms last?

Persisted until death

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

Died

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

1-38217035 - The reporter, a pet owner, indicated that her cat was exposed to an insecticidal collar containing the active ingredients tetrachlorvinphos and methoprene. The reporter placed the collar on her 4-year-old, male, domestic cat eight days prior to initial contact with the registrant and two days after the collar was applied the cat became listless, wobbly and could not use his back legs. The cat passed away the following day. No veterinary care was sought. The reporter was advised that there are numerous possible causes for the described symptoms and without pre-mortem diagnostics or a necropsy the cause for the cats illness and death cannot be determined. 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

Death

19. Provide supplemental information here