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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2376

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26224686

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.

20-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: KENTUCKY

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. Unknown

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?

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

border collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

15

7. Weight (provide a range if necessary )

80

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

  • Gastrointestinal System
    • Symptom - Bloody vomit
    • Symptom - Vomiting
    • Symptom - Anorexia
  • Renal System
    • Symptom - Blood in urine
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown/Inconnu

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

1-26224686- The reporter, a pet owner, indicates his animal may have been exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicates his fifteen year old male eighty pound border collie (Subform III, #1) had stopped eating two days prior to his initial contact with the registrant. The animal had been vomiting quite a bit according to the owner during that time frame and he had noted blood in the vomitus. He had bought the animal to the veterinarian (unspecified time) and the veterinarian had treated the animal with the anti-emetic drug Cerenia, intravenous fluids, and the oral antibiotic Cephalexin. The reporter indicates a neighbor dog (Subform III, #2) has had similar troubles described as vomiting and anorexia. The pet owner was unable to provide further information about the neighbor dog during his initial contact. The caller reports he had learned yet another neighbor had baited with the product (unspecified location) 2-3 days prior to his initial report. He was concerned his pet may have ingested the product but had not observed ingestion. The pet owner was advised of the mechanism of action, typical signs (including onset), and treatment/diagnostic protocols. On follow up the pet owner indicated he had learned his neighbor¿s dog had died. He could not provide more information regarding that animal. He indicates he had a pharmacist friend provide him with Vitamin K1, but his animal had failed to respond. The animal was, at the time of call back, described to be down unable to rise and had developed hematuria. He reported at the time of call back he had returned his animal to the veterinarian. The pet owner did not respond to further follow up attempts. No further information is available.


To be determined by Registrant

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

Major

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Vomiting
  • General
    • Symptom - Death

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

1-26224686- The reporter, a pet owner, indicates his animal may have been exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicates his fifteen year old male eighty pound border collie (Subform III, #1) had stopped eating two days prior to his initial contact with the registrant. The animal had been vomiting quite a bit according to the owner during that time frame and he had noted blood in the vomitus. He had bought the animal to the veterinarian (unspecified time) and the veterinarian had treated the animal with the anti-emetic drug Cerenia, intravenous fluids, and the oral antibiotic Cephalexin. The reporter indicates a neighbor dog (Subform III, #2) has had similar troubles described as vomiting and anorexia. The pet owner was unable to provide further information about the neighbor dog during his initial contact. The caller reports he had learned yet another neighbor had baited with the product (unspecified location) 2-3 days prior to his initial report. He was concerned his pet may have ingested the product but had not observed ingestion. The pet owner was advised of the mechanism of action, typical signs (including onset), and treatment/diagnostic protocols. On follow up the pet owner indicated he had learned his neighbor¿s dog had died. He could not provide more information regarding that animal. He indicates he had a pharmacist friend provide him with Vitamin K1, but his animal had failed to respond. The animal was, at the time of call back, described to be down unable to rise and had developed hematuria. He reported at the time of call back he had returned his animal to the veterinarian. The pet owner did not respond to further follow up attempts. 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