Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5534
2. Registrant Information.
Registrant Reference Number: PROSAR Case# 1-24357794
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.
09-OCT-10
5. Location of incident.
Country: UNITED STATES
Prov / State: MISSOURI
6. Date incident was first observed.
09-OCT-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 61282-23
Product Name: Ramik Green Mini Bait Pack
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .005 %
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name:
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
mixed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
40
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
- General
- Symptom - Hiding
- Symptom - Death
- Symptom - Parvovirus infection
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
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
1-24357794- The reporter, a pet owner, indicates his animal may have been exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicated his one year male forty pound mixed breed dog was currently hiding at the time of the initial contact with the registrant. The pet owner indicates a package of the product was missing and suspected the animal had ingested an unknown amount of the product. The pet owner was advised of an actionable ingestion in a forty pound dog. He was advised of proper decontamination and current therapeutics following an actionable ingestion. On routine call back the pet owner indicated his animal was diagnosed with a Parvoviral infection and had died. He did not provide any details about the animal¿s illness or death. 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