Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4184

2. Registrant Information.

Registrant Reference Number: 1-34363299

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.

19-JUL-13

5. Location of incident.

Country: UNITED STATES

Prov / State: IDAHO

6. Date incident was first observed.

18-JUL-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 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?

No

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

Male

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

20

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 - Lethargy

• Respiratory System
  • Symptom - Laboured breathing

• Gastrointestinal System
  • Symptom - Bloody vomit

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up
  • Symptom - Other
  • Specify - Difficulty moving

• 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

1-34363299 - The reporter, a pet owner, indicated that his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter indicated that his 3 year old, male, 20 pound mixed breed dog may have ingested the product sometime in the past 1-2 weeks prior to initial contact with the registrant. The reporter did not observe the exposure but indicated that he noticed a couple of pounds of product missing from the product container. On the day of initial contact the reporter indicated that his dog was lethargic, having labored breathing and having trouble getting up and down. Caller also reports that one day prior to initial contact with the registrant his three cats seemed lethargic and unaware of their surroundings. The reporter was advised to seek immediate veterinary care where the antidote, vitamin K1 could be prescribed. On follow-up call, four days later, the reporter indicated that his dog died and was bleeding from his mouth at the time of death. The reporter did not indicate whether or not veterinary care was ever sought. The reporter stated that his cats seemed to be doing fine. 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