Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-1212
2. Registrant Information.
Registrant Reference Number: ProPharma case: 1-42931035
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.
13-JAN-16
5. Location of incident.
Country: UNITED STATES
Prov / State: MARYLAND
6. Date incident was first observed.
12-JAN-16
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. 61282-48
Product Name: Ramik Green Bait Packs
- 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: 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
Female
6. Age (provide a range if necessary )
14
7. Weight (provide a range if necessary )
55
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 - Other
- Specify - vaginal bleeding
- Symptom - Vocalizing
- Nervous and Muscular Systems
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
1-42931035 - The reporter, a pet owner, indicated his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter did not witness the exposure but stated that he had put out 15-20 pellets in a bottle several days prior to his initial call. One day prior to his call he noticed the bottle had moved and it was empty. That was the same day he noted his 14 year old, 55 pound, female mixed breed dog was vomiting, shivering, vocalizing and had vaginal bleeding. The reporter was advised to seek immediate medical attention. If symptoms were from this product, the antidote, vitamin K1 could be given. On follow-up call, one day later, the reporter indicated that she brought her dog to the veterinarian where it was given vitamin K1 but it passed away a few hours later. 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