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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-1214

2. Registrant Information.

Registrant Reference Number: ProPharma case: 1-43036079

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.

24-JAN-16

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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?

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

Border Collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.75

7. Weight (provide a range if necessary )

20

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
  • Respiratory System
    • Symptom - Tachypnea
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - body is limp
  • Cardiovascular System
    • Symptom - Tachycardia

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

1-43036079 - 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 at the time of the call the reporter indicated his 9-month-old, 20 pound Border collie who had been fine just minutes before was now limp, breathing fast and his heart rate was fast. Caller indicated that it might be that the neighbors horse kicked the dog but it was also possible that his dog ingested a rat that was killed by the bait. The reporter was advised that secondary toxicosis is not expected from one acute exposure but given the severity of the dogs symptoms immediate veterinary care was recommend. If symptoms were from this product, the veterinarian could start the dog on the antidote, vitamin K1. On follow-up call, one day later, the reporter indicated that his dog passed away about 25 minutes after his initial phone call. 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