Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-2329

2. Registrant Information.

Registrant Reference Number: 2019-US-030410

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.

04-NOV-19

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

6. Date incident was first observed.

18-SEP-19

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. 2596-153

Product Name: Hartz UltraGuard Rid Flea and Tick Shampoo for Dogs 18oz

• Active Ingredient(s)
  • D-PHENOTHRIN
    • Guarantee/concentration ,27 %

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7. b) Type of formulation.

Liquid

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).

Please refer to field 13 on Subform II or field 17 of Subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

• Skin
  • Symptom - Rash

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Lethargy
  • Symptom - Death

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

On approximately 18-Sep-2019, an 8 year old, approximately 10 pound, intact, female, Chihuahua dog, in unknown condition, with no known concomitant medical conditions, was administered 1 dose of Hartz UltraGuard Rid Flea and Tick Shampoo for Dogs (Phenothrin) via the topical route by the animal owner. Approximately 2 hours post administration, the dog developed a rash on her back. On approximately 20-Sep-2019, the dog developed anorexia and lethargy. On approximately 22-Sep-2019, the clinical signs of anorexia and lethargy resolved. On approximately 23-Sep-2019, the dog died. The dog had not been evaluated by a veterinarian and no treatment had been performed. A necropsy was also not performed.

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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

Assessment: The active ingredient in this product is present in low concentration and has a wide margin of safety in dogs. Dermal reactions including rash are possible if an animal is sensitive to any of the product ingredients. However, delayed onset lethargy, anorexia, and sudden death are not expected. Other causes including underlying cardiac disease, trauma, cancer, and metabolic disease should be considered in this case. No veterinary evaluation or necropsy occurred so it is difficult to assess this case further. The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.