Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6363

2. Registrant Information.

Registrant Reference Number: 1-35286663

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-OCT-13

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

20-OCT-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. 61282-46

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?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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

Female

6. Age (provide a range if necessary )

10

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

• General
  • Symptom - Swelling
  • Symptom - Death

• Eye
  • Symptom - Swollen eye

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

1-35286663 - The reporter indicated that his neighbors dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that he applied the product around his home 3 weeks prior to initial contact with the registrant. About a week after product application the reporter found a couple of dead rats which were discarded. On the day of initial contact with the registrant the reporter indicated that his neighbors 10-year-old, female Pit bull Terrier had died and the pet owner, who lives two doors up from the reporter, had indicated that the dog was recently seen catching and eating a live rat. Symptoms seen prior to the dogs death were a swollen neck and a swollen eye. The pet owner was concerned that the dog died from eating a rat that had been exposed to this product. The reporter was advised that ingestion of one rat that had been exposed to this product would not be expected to cause systemic toxicity. The reporter was further advised that there are numerous possible causes for the described symptoms, especially in an elderly dog, and a necropsy was recommended to help determine an underlying cause for the dogs death. The reporter stated that the neighbors were planning on having the dog picked up by the humane society tomorrow but that he would suggest a necropsy to the owner. The reporter could not be reached for follow-up. 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