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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2401

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-40536084

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.

10-MAY-15

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

10-MAY-15

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 (unspecified)

  • 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

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

10

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 - Swelling
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up

12. How long did the symptoms last?

Persisted until death

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

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

1-40536084 - The reporter, a pet owner, indicated that his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. At the time of the initial call the reporters 7-year-old, 10 pound, female mixed breed dog was experiencing labored breathing and was lying down and not wanting to get up. Although an exposure to the product was not witnessed the reporter was concerned that his dog may have ingested a rodent that had died from ingestion of the product. The reporter was advised to seek immediate medical attention to determine an underlying cause and appropriate treatment for his dog. The reporter was further advised that if symptoms were from exposure to this product, the antidote, vitamin K1 could be given. On follow-up call, one day later, the reporter indicated that the dog was taken to a veterinarian and died as the staff was taking an x-ray. The veterinarian did not think symptoms were from exposure to the product. She had noted swelling in the dogs throat and was concerned that the animal may have had cancer. No additional 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