Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3940

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-23499806

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.

19-JUL-10

5. Location of incident.

Country: UNITED STATES

Prov / State: UNKNOWN

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. Unknown

Product Name: Ramik Green (non-specific)

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name:

• Active Ingredient(s)

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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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

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

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

• General
  • Symptom - Dehydration

• Blood
  • Symptom - Thrombocytopenia

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

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

1-23499806- The reporter, a veterinarian, indicates a patient of his was potentially exposed to a rodenticide containing the active ingredient diphacinone. The caller indicates he is evaluating a seventy pound four year male Collie dog that presents with dehydration following three days of vomiting. The veterinarian reports he has done blood chemistries which were within normal limits. He indicates the animal has no evidence of parasites. He indicates he suspects ingestion of the product but goes on to indicate no exposure was observed and does not clarify how he cane to the suspicion stated. The veterinarian was advised of actionable doses, mechanism of action, signs typically seen following ingestion, treatment/monitoring protocols and prognosis. On routine call back one of the doctor¿s staff members was reached. It was reported the animal died the day of the initial call to the registrant. The reporter indicated continued vomiting and thrombocytopenia. The veterinarian had given an injection of Vitamin K1 but the animal later died. No further information is available.

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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