Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5959

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-38511974

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.

Human

4. Date registrant was first informed of the incident.

20-SEP-14

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

20-SEP-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. 61282-46

Product Name: Ramik Green

• 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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Bizarre behaviour
  • Symptom - Unresponsive

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

Poisoning from ingestion of the pesticide

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

1-38511974 - The reporter, a healthcare professional, indicated that an adult male was exposed to a rodenticide containing the active ingredient diphacinone and to other unidentified non-company products. At the time of the initial call, the reporter was treating an adult, mentally disturbed male who two hours prior to the initial call told the paramedics that he had ingested 4 to 5 boxes of rodenticide in an attempt to commit self-harm. When the paramedics found the patient he was delirious, he became unresponsive and at the time of the call he was on a respirator. The reporter indicated that the patient did not have any underlying liver or blood clotting concerns. The reporter was advised that the described symptoms are not consistent with exposure to a rodenticide. The reporter indicated that the patient did take other unidentified products. Gastrointestinal decontamination was recommended as well as INR blood testing 24 to 72 hours after the exposure followed by treatment with vitamin K1 as needed. No further information could be provided on follow-up attempts. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.