Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1808

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-40211889

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.

10-APR-15

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

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.

Active(s)

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PMRA Registration No. 30734      PMRA Submission No.       EPA Registration No.

Product Name: UltraGuardFlea/Tick Treatment for Dogs/Puppies 14-28Kg

• 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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

30.8

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

• Gastrointestinal System
  • Symptom - Weight loss
  • Symptom - Diarrhea
  • Symptom - Anorexia

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

1-40211889 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal spot-on product containing the active ingredient phenothrin. The reporter indicated that he had applied the product to his dog for the past 3 months and since that time the dog has been losing a lot of weight. Per the reporter the last application was 3 weeks prior to initial contact with the registrant. On the day of the initial call the reporter indicated that he had just returned from the veterinary clinic and was told the cause for weight loss was due to use of the spot-on registrant product. However, later, that same day, the office manager from the veterinary clinic called the registrant and indicated that the dog has had a history of chronic weight loss for the past 3 years. Per the office manager the pet owner had not yet paid his bill for the past two visits and the office manager believed the pet owner was trying to get Hartz to pay the bill. During the dogs last visit to the clinic the pet owner showed the office manager a package of the Hartz spot-on product and per the office manager it looked as though the applicators had not yet been opened. In addition, the office manager indicated that they had recently dispensed Advantage to the pet owner for monthly flea and tick control so she is not sure why he would be using the Hartz product. The office manager also indicated that the dog was last seen at the clinic two weeks prior to the day of initial contact for treatment of weight loss, diarrhea and anorexia. During that visit a fecal was recommended to determine if the dog had parasites but this was declined by the pet owner, who stated that his dog did not have any parasites. Per the office manager it was the pet owner, not the veterinarian who indicated that the dogs symptoms were from use of the registrant product. No additional information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here