Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2394

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36905426

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.

26-APR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

6. Date incident was first observed.

25-APR-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 61282 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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.3

7. Weight (provide a range if necessary )

12

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• General
  • Symptom - Lethargy
  • Symptom - Death

• Blood
  • Symptom - Abnormal coagulation

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

1-36905426 - The reporter, a pet owner, indicated that his dog was exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that one night prior to initial contact with the registrant his 12 pound, 13-week-old, female mixed breed dog ingested about 1 ounce of the product and at the time of the initial call the reporter indicated that his dog was lethargic. The reporter was advised to immediately take his dog to the veterinarian, where the antidote, vitamin K1, could be given. On follow-up call, two days later, the reporter indicated that he brought his dog to the veterinarian on the day of his initial call. The reporters dog passed away at the veterinary clinic while receiving a blood transfusion. Per the reporter no bleeding was evident but a PT blood test was prolonged. 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