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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3939

2. Registrant Information.

Registrant Reference Number: Prosar 1-20828551

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.

24-NOV-09

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

24-NOV-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. 61282-48

Product Name: Ramik Green Bait Packs

  • 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?

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

Unknown 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 )

70

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Anorexia
  • 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

1-20828551: A reporter (dog owner) called on 11/24/2009 to report the exposure of her 2 dogs to an anticoagulant bait containing the active ingredient Diphacinone. According to the reporter, the reporter's children were playing with the packs and left them on the deck 1 week prior to the report. The dogs ingested approximately 2 ounces between the 2 of them. The dogs appeared fine until 11/24/2009 when Dog #1 (1st Subform III) developed anorexia and lethargy. At the time of the report, Dog #2 was not having any signs. The reporter was advised that veterinary evaluation is recommended based on the amount of product potentially ingested. The product takes 2-5 days to take effect in the body, at which time it interferes with blood coagulation. Signs of bleeding were discussed. The reporter was advised that Vitamin K1 is the antidote and must be obtained through a veterinarian. On follow up, the reporter stated that Dog #1 was not taken to a veterinarian and had died at home on 11/27/2009. Dog #2 was euthanized at an unknown time. It is unknown what, if any signs, were noted in Dog #2. 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