Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3680

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-41197134

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.

08-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

01-JUL-15

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.

Product Name: UltraGuard Rid Flea/Tick Shampoo for Dogs

• 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?

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

Jack Russell Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

20

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Skin
  • Symptom - Bleeding
  • Symptom - Irritated skin

• General
  • Symptom - Biting

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

14. a) Was the animal hospitalized?

Unknown

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

1-41197134 - The reporter, a pet owner, indicated that her dog was exposed to an insecticidal shampoo containing the active ingredients pyrethrins, n-octyl bicycloheptene dicarboximide and piperonyl butoxide. The reporter shampooed her 9-year-old, 20 pound, female Jack Russell Terrier with the shampoo seven days prior to initial contact with the registrant. The following day the pet owner noted raw and bleeding spots in various places on the dog. At the time of the initial call, the dog was still biting at her skin and some of the affected areas were the size of a silver dollar. The reporter was advised that there are numerous possible causes for the described symptoms but it may be that her dog has a sensitivity to the product. Due to the persistence of the described symptoms medical attention was recommended. The reporter could not be reached on routine follow-up attempts. 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

Moderate

19. Provide supplemental information here