Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-3438

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-48547956

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.

09-JUN-17

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

09-JUN-17

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. 61282-26

Product Name: RAMIK MINI BARS ALL WEATHER RAT AND MOUSE KILLER

• 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?

No

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

Jack Russell Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

10

lbs

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
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Eye
  • Symptom - Glazed eye

• Gastrointestinal System
  • Symptom - Stomach pain

12. How long did the symptoms last?

Persisted until death

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

Yes

14. a) Was the animal hospitalized?

Unknown

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

1-48547956 - The reporter, an animal owner, indicated her dog might have been exposed to a rodenticide both containing the active ingredient diphacinone (present in free form or as sodium salt). On the day of initial contact with the registrant, the reporter indicated her 1-year-old, 10-pound, female, Jack Russell Terrier dog was lethargic, ataxic, had glazed-over eyes, and seemed like her abdomen was painful. The reporter had put the product out in her home two days before the day of initial contact. The reporter was advised to get immediate medical attention for the dog as the symptoms were consistent with product toxicity. The reporter was not available on follow-up call three days later, however on follow-up call four days later, the reporter indicated the dog had died in the car at the emergency clinic. 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