Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2027

2. Registrant Information.

Registrant Reference Number: PROSAR Case #1-25949519

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.

22-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

6. Date incident was first observed.

21-APR-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)

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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: Res. - Out Home / Rés - à l'ext.maison

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

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

55

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

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Lethargy
  • 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

1-25949519- The reporter, a pet owner, indicates his animal may have been exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicated he had placed the product in a Styrofoam cup on his porch two days prior to his initial report. He indicates the following morning he noted four ¿ inch pellets were missing from the product he had place on the porch. He indicates his ten year fifty five pound female Labrador retriever had access to the product and was concerned the animal had eaten the product. He did not observe and ingestion. The caller reports the animal demonstrated the signs of lethargy and loss of appetite the morning of his initial contact with the registrant. The pet owner was advised the animal had ingested 8.4-10 grams based on his description. An actionable ingestion in a fifty five pound dog would be 49.5 grams. Despite the fact that toxicity would not be expected he was advised to seek prompt veterinary attention for the signs seen. He was advised of the mechanism of action of the active ingredient, standards of care, and prognosis. Follow up was obtained four days later. At this point the caller indicated the animal had died one day following his initial contact. He had not sought veterinary assistance. The caller indicated he had thought the animal had died due to a hookworm infestation, but was unable to substantiate the assertion. No further information is available.

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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