Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6364
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-35349003
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.
27-OCT-13
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 61282-26-3
Product Name: Harris 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?
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
Labrador Retriever
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
45
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.
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
1-35349003 - The reporter indicated that her dog was exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that eight to nine days prior to initial contact with the registrant both of her dogs got into the container and ingested 6 to 8 ounces of this product. At the time of initial contact the reporter stated that her 7-year-old, 45 pound, male Labrador retriever (Subform III #1) had some swelling in his front leg and shoulder and was not eating. The reporters other dog was asymptomatic. The reporter was advised to seek veterinarian care for both of her dogs, where the antidote, vitamin K1, could be given. On follow-up call, one day later, the reporter indicated that she did not take her sick dog (Subform III #1) to the veterinarian and it died at home on the morning of the follow-up call. The other dog had been taken to the veterinarian and was being treated with vitamin K1. 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