Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0125

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-39329094

Registrant Name (Full Legal Name no abbreviations): HACCO, Inc.

Address: 110 Hopkins Drive

City: Randolph

Prov / State: Wisconsin

Country: USA

Postal Code: 53956

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

28-DEC-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

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.       PMRA Submission No.       EPA Registration No. 61282-48

Product Name: Ramik Green

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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

Unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

85

lbs

8. Route(s) of exposure

Unknown

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 - Death

• Respiratory System
  • Symptom - Coughing

• Nervous and Muscular Systems
  • Symptom - Seizure
  • Symptom - Paralysis
  • Symptom - Difficulty getting up

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-39329094 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. Although no exposure to the product was witnessed and there was no evidence that the reporter's dog got into the product (The reporter never noted green stool or disturbance of the application site). The registrant product had been placed under the porch about one week prior to the initial call and three days prior to initial contact the reporters 85 pound, 13-year-old dog had a seizure and then started coughing. The dog was then let outside and after it came back inside it could no longer stand. The dog died about one hour later. The reporter did not seek veterinary care. The reporter was advised that there are numerous possible causes for the described symptom and a necropsy was recommended to help determine an underlying cause. 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

Death

19. Provide supplemental information here