Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0652

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-35997888

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-JAN-14

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

17-JAN-14

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. 61282-23

Product Name:

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Loss of appetite

• General
  • Symptom - Vocalizing
  • Symptom - Lethargy
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Other
  • Specify - green stool

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

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

1-35997888 - The reporter, the brother of the pet owner, indicated that his brother's dog may have been exposed to a rodenticide containing the active ingredient diphacinone. At the time of the initial call the reporter stated that his brother's 1 year old, 50 pound, female Pit bull mexed breed dog had been acting weird; it was lethargic and whining while eating. The reporter initially thought the dog's symptoms might be because she had gotten pregnant or because she had been chewing on a dead squirrel but then he remembered that two days prior to initial contact with the registrant the dog had knocked over a garbage can where two 1.5 ounce bags of this product had been placed. The reporter indicated that he did notice that the dog had green stool after the exposure. The reporter was advised that there are numerous possible causes for the described symptoms including a GI foreign body. Immediate veterinary care was recommended to determine an underlying cause and appropriate treatment for the described symptoms. The reporter was further advised that if symptoms were from exposure to this product the veterinarian could treat the dog with the antidote, vitamin K1. On follow up call, two days later, the reporter stated that the dog was brought to the veterinarian on the day of initial contact. The veterinarian did not run any tests to determine the cause for the symptoms but he did prescribe vitamin K1. During the visit the veterinarian had indicated that they could start the dog on 'extensive and expensive treatment' but the veterinarian thought it would ultimately not end up helping the dog. The dog died at home later that evening. Per the reporter no obvious bleeding was seen. No further information is available.

---

To be determined by Registrant

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

Moderate

19. Provide supplemental information here