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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0615

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-39489706

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.


5. Location of incident.


Prov / State: ALABAMA

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Ramik Green

  • Active Ingredient(s)
      • Guarantee/concentration .005 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Unknown / Inconnu

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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Bloody vomit
    • Symptom - Bloody stool

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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 39489706 The reporter, a pet owner, indicated that his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter indicated that the product was applied (Reporter did not indicate if it was applied inside or outside the home.) two days prior to initial contact with the registrant and sometime within 6 8 hours of the initial call the reporter s 3 year old, female Pekingese dog may have accessed the product. At the time of the initial call the reporter indicated that for the past 4 5 hours the dog had been vomiting blood and had had bloody stool. The reporter was advised that we would not expect symptoms from this product for a period of at least 48 hours and there was likely something else affecting the dog s health. Immediate veterinary care was recommended to determine an underlying cause and appropriate treatment. On follow up call, two days later, the reporter indicated that the dog was taken to the veterinarian on the day of initial contact. The veterinarian ran an unspecified blood test which per the reporter indicated that the dog had not been exposed to a rodenticide. The veterinarian diagnosed the dog with a disease commonly seen in brachycephalic dogs but the reporter could not remember the name of the disease. The dog passed away later that night. No additional information is available.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here