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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5553
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15101643
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.
12-JUL-075. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
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.
Product Name: Ramik Green
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
7. b) Type of formulation.
Granular
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: Home Garden
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
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
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- General
- Symptom - Death
- Symptom - Hemorrhage
- Specify - found in pool of blood
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller states her boyfriend applied product in garden two weeks ago. Within the last week caller states two of her dogs have passed away after owner found them lying in a puddle of blood in the yard. Caller states her other dog is being treated at DVM for LAAC toxicity with Vit K1. Caller at this time is also concerned about the fact that product was applied to the garden and she has vegetables that are ripe. Caller wants to know if it is safe to eat the vegetables now. Assessment: Sorry for your losses and I'm glad your other dog is being treated. Product is not intended for use on garden vegetables. Wouldn't anticipate any adverse health effects from ingesting vegetables. Would recommend that any vegetables with a skin be thoroughly washed before ingestion. If concerned for any reason, err on the side of safety and do not consume any vegetable that was exposed to product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.5
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
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- General
- Symptom - Death
- Symptom - Hemorrhage
- Specify - found in pool of blood
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller states her boyfriend applied product in garden two weeks ago. Within the last week caller states two of her dogs have passed away after owner found them lying in a puddle of blood in the yard. Caller states her other dog is being treated at DVM for LAAC toxicity with Vit K1. Caller at this time is also concerned about the fact that product was applied to the garden and she has vegetables that are ripe. Caller wants to know if it is safe to eat the vegetables now. Assessment: Sorry for your losses and I'm glad your other dog is being treated. Product is not intended for use on garden vegetables. Wouldn't anticipate any adverse health effects from ingesting vegetables. Would recommend that any vegetables with a skin be thoroughly washed before ingestion. If concerned for any reason, err on the side of safety and do not consume any vegetable that was exposed to product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
