Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5150
2. Registrant Information.
Registrant Reference Number: PROSAR Case #1-24209270
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-SEP-105. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
26-SEP-10Product 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 %
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
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
Chihuahua
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
20
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Blood
- Symptom - Bleeding
- 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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-24209270- The reporter, a pet owner, indicates her animals were exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicates she was away from her home for one day at which point her two Chihuahua dogs ingested one half of a one pound container of the product. The first animal, a twenty pound two year male dog (Sub-form III#1), was found dead on arrival home with evidence of bleeding. The second animal, a six month male dog (Sub-form III#2), was showing obvious signs of bleeding at the time of the initial contact with the registrant. The caller was advised to seek prompt veterinary care for the remaining animal, typically the active ingredient does not exert effects within the first twelve hours of ingestion. On routine call back the owner reported the second animal died before she could get it to the veterinarian¿s. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Blood
- Symptom - Bleeding
- 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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-24209270- The reporter, a pet owner, indicates her animals were exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicates she was away from her home for one day at which point her two Chihuahua dogs ingested one half of a one pound container of the product. The first animal, a twenty pound two year male dog (Sub-form III#1), was found dead on arrival home with evidence of bleeding. The second animal, a six month male dog (Sub-form III#2), was showing obvious signs of bleeding at the time of the initial contact with the registrant. The caller was advised to seek prompt veterinary care for the remaining animal, typically the active ingredient does not exert effects within the first twelve hours of ingestion. On routine call back the owner reported the second animal died before she could get it to the veterinarian¿s. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
