Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4863

2. Registrant Information.

Registrant Reference Number: 1-34641160

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.

16-AUG-13

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 61282-46

Product Name: Ramik Green

• 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?

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

Pit Bull Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

80

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

• Respiratory System
  • Symptom - Coughing up blood

• General
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Bloody vomit

12. How long did the symptoms last?

Persisted until death

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

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

1-34641160 - The reporter, a pet owner, indicated that her dog was exposed to a rodenticide containing the active ingredient diphacinone. The reporter indicated that her 2 year old, 75 pound, female Pit Bull Terrier may have ingested an unknown amount of this product on the day of initial contact. The dog was found eating out of the bag just prior to the caller. The reporter was advised to induce emesis and then take her dog to the veterinarian, where the antidote, vitamin K1, could be given. On follow-up call 7 days later the reporter indicated that she induced emesis in her female dog and it never developed any symptoms but her male, 3-year-old, 80 pound Pit Bull Terrier (Subform III #1) was now either coughing or vomiting up blood. This male dog had not been mentioned during the initial call 7 days earlier. The reporter was advised to immediately take her male dog to her veterinarian. On follow up call, three days later, the reporter indicated that she had called her veterinarian who told her that there was nothing that he could do for her male dog and the following morning the dog was found dead. 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