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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3718

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-34064034

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-JUN-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

20-JUN-13

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 (unspecified)

  • 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

mixed breed

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

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

  • 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?

Other / Autre

specify reason unknown/unclear

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-34064034 - The reporter, a pet owner, indicated that his dogs may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter indicated that his elderly neighbor has been seen feeding this product to his outdoor dogs. The reporter is unsure if the neighbor believes that he is feeding dog food or intentionally poisoning his dogs. The reporter indicated that one of the dogs was found dead at the time of initial contact. A second dog, a mixed breed dog of unknown age, is not himself and is not eating. The reporter believes that this dog has been poisoned as the symptoms have been ongoing for 5 to 6 days. The reporter had called his veterinarian who recommended therapy with Vitamin K1. The reporter contacted the registrant for the proper dose of Vitamin K1 for his dog. The reporter was advised to seek immediate veterinary care for his dog. The veterinarian may perform blood tests to determine exposure. Two attempts were made for follow up. The pet owner did not respond to either. No other 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

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

75

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

  • General
    • Symptom - Malaise
  • Gastrointestinal System
    • Symptom - Anorexia

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify reason unknown/unclear

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-34064034 - The reporter, a pet owner, indicated that his dogs may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter indicated that his elderly neighbor has been seen feeding this product to his outdoor dogs. The reporter is unsure if the neighbor believes that he is feeding dog food or intentionally poisoning his dogs. The reporter indicated that one of the dogs was found dead at the time of initial contact. A second dog, a mixed breed dog of unknown age, is not himself and is not eating. The reporter believes that this dog has been poisoned as the symptoms have been ongoing for 5 to 6 days. The reporter had called his veterinarian who recommended therapy with Vitamin K1. The reporter contacted the registrant for the proper dose of Vitamin K1 for his dog. The reporter was advised to seek immediate veterinary care for his dog. The veterinarian may perform blood tests to determine exposure. Two attempts were made for follow up. The pet owner did not respond to either. No other information is available.


To be determined by Registrant

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

Minor

19. Provide supplemental information here