Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0126
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-38970591
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.
20-NOV-14
5. Location of incident.
Country: UNITED STATES
Prov / State: IDAHO
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
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .005 %
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 )
3
7. Weight (provide a range if necessary )
80
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
- General
- Symptom - Death
- Symptom - Lethargy
- Symptom - Hemorrhage
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-38970591 - The reporter, a pet owner, indicated that her dog was exposed to a rodenticide containing the active ingredient diphacinone. The caller was unable to locate an EPA registration number on the package and only provided the partial name of Ramik. The reporter stated that she had been on vacation for a week and during that time period her brother was coming to her house to let her 3-year-old, 80 pound dog outside. She arrived home on the evening of initial contact and noticed that her dog was lethargic and that there was blood in the dogs kennel. The reporter was advised to seek immediate medical attention where the antidote, vitamin K1, could be given. On follow-up call, two days later, the reporter indicated that her dog passed away two hours after her initial call. No veterinary care was sought. The reporter also indicated that the dog had been getting the product from a package at the neighbors house and she estimated that the dog ingested about 3/4s of the package or 72 grams of bait. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here