Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2824
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-30390529
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.
05-JUN-12
5. Location of incident.
Country: UNITED STATES
Prov / State: MISSOURI
6. Date incident was first observed.
05-JUN-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 61282-26
Product Name: Ramik Mini Bars All Weather Rat Mouse Killer
- 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
Coonhound
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
50
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
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
1-30390529- The reporter, a pet owner, indicates his animal had been exposed to rodenticide containing the active ingredient diphacinone. The reporter indicated his six year fifty pound male Coon hound had ingested the product just before his initial contact. The pet owner was advised to seek immediate veterinary care. He was advised of the mechanism of action and the standard of care following accidental ingestion in domestic animals. The reporter was reached three days later for follow up. The reporter did not provide detail but indicated the animal had died. The caller then disconnected and no further information was provided.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here