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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0041
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-37740311
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.
09-JUL-145. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
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)PMRA Registration No. PMRA Submission No. EPA Registration No. Unknown
Product Name: Ramik Green
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .005 %
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
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
Male
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
35
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
- Blood
- Symptom - Bleeding
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
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?
Intentional poison./Empois. intentionnel
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-37740311 - The reporter, a pet owner, indicated that her dog was exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that she was concerned that someone was trying to poison her dog because for the past week she had been finding packs of the product in her yard. One day prior to initial contact with the registrant the callers 35 pound, male, Red nose American Pit Bull mixed breed dog was found with a bag of the product in his mouth and he may have ingested some. Later that same day the dog was bleeding from his nose and mouth after potentially getting in a fight with a cat. At the time of the initial call the dog was still not doing well. The reporter was advised to take her dog to the veterinarian where the antidote, vitamin K1, could be given. On follow-up call, five days later, the reporter indicated that her dog died about 20 minutes after her initial call. No veterinary care was provided. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
