Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0045

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-37967159

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.

30-JUL-14

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

30-JUL-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. 13359      PMRA Submission No.       EPA Registration No.

Product Name: Ramik Green Bait Packs

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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

Golden Retriever

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5.5

7. Weight (provide a range if necessary )

65

lbs

8. Route(s) of exposure

Unknown

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

• Respiratory System
  • Symptom - Difficulty Breathing

• General
  • Symptom - Lethargy
  • Symptom - Other
  • Specify - Infection

• Blood
  • Symptom - Leukocytosis

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

Fully Recovered / Complètement rétabli

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

1-37967159 - 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 about 8-10 hours prior to initial contact with the registrant his 65 pound, 5.5-year-old, male Golden Retriever may have had access to the product. The exposure was not witness but at the time of the initial call the dog was lethargic. The reporter was advised that there are numerous possible causes for lethargy and symptoms from exposure to this product are not typically seen for 2-5 days. Veterinary care was recommended to determine an underlying cause for the dogs symptom and treatment with the antidote, vitamin K1 was advised if blood work indicated the dog had been exposed to the product. On follow-up call, two days later, the reporter indicated that the dog was currently at the veterinary clinic as it had started to have trouble breathing. On follow-up call, six days after the initial call, the reporter indicated that blood work showed increased white blood cells. The dog was diagnosed with some unspecified infection and was placed on an antibiotic. At the time of the follow-up call the dog was fine. 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

Moderate

19. Provide supplemental information here