Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1407

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36379674

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.

06-MAR-14

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. 612282-12

Product Name: Ramik Bars All-Weather Rat and Mouse Killer

• 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?

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

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.2

7. Weight (provide a range if necessary )

Unknown

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

• Respiratory System
  • Symptom - Other
  • Specify - sneezing blood

• General
  • Symptom - Death

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?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify No exposure witnessed

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-36379674 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that her 20 pound, male mixed breed dog started sneezing one day prior to initial contact with the registrant and on the day of contact the dog was lethargic and not eating. No exposure to the registrant product was witnessed and there was no evidence of missing product but the reporter was concerned that her pets symptoms might be from exposure to this product. The reporter was advised that there are numerous possible causes for the described symptoms and immediate veterinary care was recommended to determine an underlying cause and appropriate treatment. 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. The reporter then stated that about 3 to 4 weeks prior to her call her 10 week old unvaccinated puppy (Subform III #1) passed away. No exposure to the registrant product was witnessed but the reporter indicated that this puppy was sneezing blood for about 2 days. They brought the puppy to the veterinarian where it died. Per the reporter the veterinarian did not know the cause of the puppys death. A follow-up call regarding the reporter s male, 20 pound dog was made one day after the initial call. The reporter indicated that she did take her 20 pound, male mixed breed dog to the veterinarian where a PT test was run and found to be normal. The reporter then stated that this dog had recently eaten a dead bird and she thought its symptoms might be due to ingestion of the bird. The veterinarian had given the dog some unknown medications and it was now doing better. 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

1-36379674 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that her 20 pound, male mixed breed dog started sneezing one day prior to initial contact with the registrant and on the day of contact the dog was lethargic and not eating. No exposure to the registrant product was witnessed and there was no evidence of missing product but the reporter was concerned that her pets symptoms might be from exposure to this product. The reporter was advised that there are numerous possible causes for the described symptoms and immediate veterinary care was recommended to determine an underlying cause and appropriate treatment. 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. The reporter then stated that about 3 to 4 weeks prior to her call her 10 week old unvaccinated puppy (Subform III #1) passed away. No exposure to the registrant product was witnessed but the reporter indicated that this puppy was sneezing blood for about 2 days. They brought the puppy to the veterinarian where it died. Per the reporter the veterinarian did not know the cause of the puppys death. A follow-up call regarding the reporter s male, 20 pound dog was made one day after the initial call. The reporter indicated that she did take her 20 pound, male mixed breed dog to the veterinarian where a PT test was run and found to be normal. The reporter then stated that this dog had recently eaten a dead bird and she thought its symptoms might be due to ingestion of the bird. The veterinarian had given the dog some unknown medications and it was now doing better. No further information is available.