Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0664

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-28648298

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.

13-JAN-12

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

13-JAN-12

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. 61282-12

Product Name: Ramik Bars All Weather Rat Mouse Killer

• 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?

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

Pit Bull

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

60

lbs

8. Route(s) of exposure

Oral

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

• Eye
  • Symptom - Glazed eye

• Blood
  • Symptom - Bleeding

• 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?

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

1-28648298-The reporter, a pet owner, indicated his animal may have been exposed to a rodenticide containing the active ingredient diphacinone. The pet owner indicated his two year male sixty pound Pit Bull terrier may have ingested an unknown quantity of the product the day prior to his initial contact. The animal was asymptomatic at the point of the initial contact. The pet owner was advised of the ingested volume that would require veterinary care, signs that may be seen, onset of signs, and current standards of veterinary care. The pet owner was advised to seek immediate veterinary care. On follow up the pet owner indicated he had taken the animal to the veterinarian the day of initial contact. At that point he had noted the animals eyes were "glassy". The veterinarian had given the animal an injection but no oral medication to go home. The animal was not hospitalized. The pet owner indicted he had noted the animal bleeding from the mouth the day after his initial contact. The animal died two days later. It was not taken back to the veterinarian. The pet owner indicated on follow up the animal may have also ingested another rodent bait at the same time of the initial ingestion, but he was unable to quantify the ingestion or identify the product or active ingredient. 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