Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0004

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-46315433

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.

20-NOV-16

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

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)

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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 %

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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).

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

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

4

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

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

• Eye
  • Symptom - Other
  • Specify - mydriasis

• General
  • Symptom - Vocalizing

• Ear
  • Symptom - Other
  • Specify - discharge

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

1-46315433 - The reporter, a pet owner, indicated his cat may have been exposed to a rodenticide containing the active ingredient diphacinone (present in free form or as sodium salt). On an unknown day before the day of initial contact with the registrant, the reporter assumes his 6-year-old, 4-pound, male cat of unknown breed must have ingested an unknown amount of the product. On the day of initial contact, the cat had difficulty getting up, was vocalizing, and his pupils were very large. The reporter didnt know if the cats condition was because of ingestion of the product or if he had been attacked by a coyote. The reporter was advised to seek immediate veterinary attention for the pet as he seemed to be in critical condition. On follow-up one day later, the reporter was unable to be reached. On follow-up three days later, the reporter stated the cat had died soon after he had gotten off the phone with the registrant. The reporter believed the cat died of an ear infection as he had developed ear discharge. The reporter was unable to get veterinary care for the cat. 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