Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5551
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-14944996
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-MAY-07
5. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 61282
Product Name: Ramik Green Bait Packs
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
7. b) Type of formulation.
Other (specify)
Pellets
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Other / Autre
Préciser le type: Feed Mill
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
Cat / Chat
3. Breed
Unknown Breed
4. Number of animals affected
5
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
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
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
Not recovered / Non rétabli
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
A local feed mill has been using the identified Rodenticide. The Owner believes that her six cats have been ingesting the bait from the mill. Five of her cats have already died. Their symptoms before death are unclear. The owner does not know if or how much bait the cats ingested. No Veterinary Care received.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here