Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-3935
2. Registrant Information.
Registrant Reference Number: Prosar 1-19650447
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.
26-AUG-09
5. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
6. Date incident was first observed.
26-AUG-09
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. 61282-46
Product Name: Ramik Green
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .005 %
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
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
60
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 - Pale mucous membrane colour
- General
- Symptom - Lethargy
- Symptom - Death
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
1-19650447: A reporter (dog owner) called on 08/26/2009 to report the exposure of his dog to a rodenticide containing the active ingredient Diphacinone. According to the reporter, the dog ingested an entire bag of product on 08/25/2009. At the time of the report, the dog had dilated pupils, white mucous membranes, anorexia, and lethargy. The reporter stated that his veterinarian told him not to bring the dog in for evaluation as they could only induce vomiting. The reporter was advised that the estimated toxic dose for the dog is 54 grams of bait. The product interferes with blood coagulation. The reporter was advised to bring his dog to the veterinarian immediately for treatment and the antidote vitamin K1. On follow up on 08/27/2009, the reporter stated that the dog was not brought to the veterinarian and died the morning of 08/27/2009. No further information was obtained.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here