Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3937

2. Registrant Information.

Registrant Reference Number: Prosar 1-20404644

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.

13-OCT-09

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSOURI

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. 61282-26

Product Name: Ramik Mini Bars All Weather Rat/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?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

The product was applied inside a shed at an unknown time.

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

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.5

7. Weight (provide a range if necessary )

10

lbs

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

• Gastrointestinal System
  • Symptom - Weight loss

• Nervous and Muscular Systems
  • Symptom - Recumbent

• General
  • 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?

Other / Autre

specify Unknown if exposure occurred

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-20404644: A reporter (cat owner) called on 10/13/2009 to report the possible exposure of his cat to a rodenticide containing that active ingredient Diphacinone. According to the reporter, the cat had been missing for 5-6 days. At the time of the report, the cat had just been located and had lost a lot of weight and was barely moving. The reporter noted that approximately 1/4 of the product that had been placed in a shed was missing. It was unknown whether that cat had ingested the product or not. The reporter was advised that the toxic dose for his cat is more than than the amount of product that is missing. Signs of product toxicity were reviewed, but the reporter was advised that the cat's signs are unlikely to be related to the product. A recommendation was made to have the cat evaluated immediately by a veterinarian. The appropriate blood testing and antidote were discussed should the veterinarian believe the cat's signs are product-related. On follow up, the reporter's wife stated that the cat died before they could get him to the veterinarian. No further information was obtained.

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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