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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0127

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-39015731

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.

14-NOV-14

5. 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. 61282-12

Product Name: Ramik Bars All Weather Rat/Mouse Killer

  • 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?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

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

Other / Autre

specify Goat

3. Breed

Nubian

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

150

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
  • Respiratory System
    • Symptom - Laboured breathing
  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Salivating excessively
  • Skin
    • Symptom - Cyanosis
  • General
    • Symptom - Pale mucous membrane colour
    • Symptom - Polydipsia
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • Respiratory System
    • Symptom - Respiratory failure

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

1-39015731 - The reporter, a pet owner, indicated that her goat may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that she put 4 bars of the registrant product under her house where her goat would not have been able to access the product. But at the time of the initial call her 9 year old, 150 pound, Nubian goat was lethargic, drinking large amounts of water, foaming at the mouth and her gums and tongue were a pale bluish color. Although no exposure to the product was witnessed the caller was concerned that the rats may have moved the bars out from under the house so the goat may have been able to access them. The reporter was advised to seek immediate medical attention to determine an underlying cause and appropriate treatment. If symptoms were from this product the veterinarian could give the antidote, vitamin K1. On follow-up call, four days later, the reporter indicated that her goat started having seizures shortly after her initial call and then she stopped breathing. The veterinarian did not have time to exam the goat before it passed away. 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