Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7262

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-45310005

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.

20-AUG-16

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

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. Unknown

Product Name: RAMIK GREEN KILLS RATS & MICE

• 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).

Site: Unknown / Inconnu

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

Chihuahua

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

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

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Bloody vomit

• General
  • Symptom - Lethargy

• Respiratory System
  • Symptom - Laboured breathing
  • Symptom - Respiratory failure

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

1-45310005 - The reporter, a pet owner, indicated her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter did not witness an exposure. On the day of initial contact with the registrant, the reporter indicated her 2-year-old Chihuahua dog of unknown weight, and gender may have ingested an unknown amount of the product three to four days before. Approximately three days before initial contact, the reporter said the dog vomited. One day before initial contact the dog developed bloody vomit. On the day of initial contact the dog also developed lethargy and labored breathing. The reporter was advised to get immediate veterinary attention for the dog as the symptoms are very concerning and the dogs prognosis is likely poor. The reporter was not available on follow-up call two days later. On follow-up call three days later, the reporter indicated the dog had stopped breathing and died after speaking to the registrant. The reporter was unable to seek veterinary care for the dog. 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