Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4225

2. Registrant Information.

Registrant Reference Number: PROSAR 1-22896433

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.

04-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

04-JUN-10

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. 61282-46

Product Name: Ramik Green

• 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: Unknown / Inconnu

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

The reporter indicated merely the product was "put out several days ago." It is unknown if this was in or out of her residence.

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

Jack Russell Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

12

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

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

• Gastrointestinal System
  • Symptom - Anorexia

• Nervous and Muscular Systems
  • Symptom - Ataxia

• General
  • Symptom - Pain
  • 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

1-22896433- The reporter, a pet owner, called to indicate her animal was exposed to a rodenticide containing the active ingredient diphacinone. The animal, a 12-15 pound male Jack Russell Terrier dog, had several days ago been seen with a package of the product after the owner had laid out the product in an unspecified manner and location in a residential setting. The exposure was approximated to be 4+ days prior to the initial contact with the registrant. The owner was not able to free the product from the animal, and the subsequent ingestion was of an unknown quantity. The animal was at the time of the initial contact demonstrating signs of anorexia, ataxia, apparent pain of unknown nature, and was down unable to rise. The caller was advised to seek prompt veterinary care, was advised of antidotes, and treatment protocols following ingestion. The caller was further advised treatment can be complicated if the animals present several days following substantial ingestion and are symptomatic. On routine call back the owner indicated the animal had died. She indicated she had phoned a veterinarian and was turned away. The veterinarian had stated nothing could be done for the animal. This opinion would not conform to current veterinary emergency and critical care standards of care. The pet owner stated she gave her animal one of her own "sleeping pills" (the product was unspecified) and the animal never "woke up." The owner indicated her intention was to alleviate pain, but did not indicate her intention was euthanasia. No further information is known.

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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