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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-1147
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-36295129
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.
25-FEB-145. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
24-FEB-14Product 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. 22851 PMRA Submission No. EPA Registration No.
Product Name: Ramik Barres All-Weather Rat and Mouse Killer
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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 )
12
7. Weight (provide a range if necessary )
120
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Bloody diarrhea
12. How long did the symptoms last?
Unknown / Inconnu
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
Unknown/Inconnu
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
1-36295129 - The reporter, a pet owner, indicated that his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that his 120 pound, 12-year-old, male mixed breed dog had developed bloody diarrhea one day prior to initial contact with the registrant. Although no exposure to the registrant product was witnessed the reporter indicated that one bar of the product was missing. 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, one day later, the reporter indicated that he brought his dog to the veterinarian shortly after his initial call. His dog was treated with an injection of vitamin K1 and sent home on oral vitamin K1 and yogurt. At the time of the follow-up call the dog was doing better, but still had some blood in his stools. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
