Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3690

2. Registrant Information.

Registrant Reference Number: Prosar case : 1-40828042

Registrant Name (Full Legal Name no abbreviations): HACCO, Inc.

Address: 110 Hopkins Dr.

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.

05-JUN-15

5. Location of incident.

Country: UNITED STATES

Prov / State: KANSAS

6. Date incident was first observed.

04-JUN-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)

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

Product Name: Ramik Green

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

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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).

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?

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

Male

6. Age (provide a range if necessary )

0.41

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Oral

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

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Diarrhea
  • Symptom - Anorexia
  • Symptom - Bloody stool

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?

Unknown

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

1-40828042 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. Two days prior to initial contact with the registrant the reporters 5-month-old, 10 pound mixed breed dog ran loose all day through the neighbors property. The following day the dog was vomiting and not eating. These symptoms persisted through the next day and then that night blood started coming out of the dogs rectum. The dog was brought to the veterinarian and at the time of the initial call the dog was at the clinic. The veterinarian had run a parvovirus test and checked for antifreeze exposure and both tests came back negative. The reporter called her neighbor who indicated that she did have some Ramik green on her property that the dog may have accessed but no exposure to the product had been witnessed. The reporter was advised that although the dog tested negative for parvovirus this test can be falsely negative and given the age of the dog and the described symptoms this should still be considered as possible differential. The reporter was further advised that if symptoms were from exposure to this product the antidote is vitamin K1 but once bleeding has begun the dog often needs additional treatment. On follow-up call, five days later, the reporter indicated that the veterinarian sent the dog home on vitamin K1 but the dog died at home. No additional information is available.

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To be determined by Registrant

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

Death

19. Provide supplemental information here