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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1321

2. Registrant Information.

Registrant Reference Number: PROSAR Case #1-25308716

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.

03-FEB-11

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSISSIPPI

6. Date incident was first observed.

03-FEB-11

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. 61282-48-66325

Product Name: Venom M-Bomb-R

  • 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

Labrador retriever

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Anorexia
  • 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

1-25308716- The reporter, a pet owner, indicates exposure of his animal to a rodenticide containing the active ingredient diphacinone. The pet owner states his thirteen week twenty five pound male Labrador retriever had ingested an unknown amount of the product the evening prior to his initial contact with the registrant. The animal demonstrated lethargy the morning of the caller¿s initial contact. The pet owner was advised to seek prompt veterinary care. He was advised of the standards of care and prognosis following accidental ingestion of the product. On routine call back the pet owner indicated the animal had died the day after his initial contact. He indicated the only additional sign seen was loss of appetite. The animal was found dead in the morning. He had not sought veterinary assistance.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here