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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0823

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-24733060

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.

17-NOV-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

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)

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 %

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

Vizsla

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

43

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

  • Blood
    • Symptom - Bleeding
    • Symptom - Other
    • Specify - "Bust blood vessel"
  • 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?

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

1-24733060- The reporter, a pet owner, calls to indicate exposure of his animal to a rodenticide containing the active ingredient diphacinone. The pet owner calls to indicate his six year forty-three pound Vizsla dog may have ingested the product while he was away from his home on vacation. The caller indicated the pregnant animal died at the veterinarian six days prior to the initial contact with the registrant. The caller indicates the animal was acting ¿¿¿real bad? 11/11/10 but did not explain what was meant by ¿¿¿real bad?. He indicates he brought the animal to the veterinarian but did not mention the potential exposure to the product. The veterinarian attempted surgical intervention to address bleeding. The caller indicated a ¿¿¿burst blood vessel?. The animal was returned to the veterinary clinic following the surgery bleeding from numerous locations. The veterinarian was unable to save the animal. The caller stated at no point had he mentioned the exposure to the veterinarian. The caller was advised of standardized protocols to treat exposure of domestic animals to anticoagulant rodenticides. Prognosis tends to be good following such exposures if addressed in a timely fashion. 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