Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2929

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-47729397

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.

06-APR-17

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

6. Date incident was first observed.

05-APR-17

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. 61282-12-270

Product Name: Rodentex Multi-feed bars

• 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

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.15

7. Weight (provide a range if necessary )

5

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

• Gastrointestinal System
  • Symptom - Bloody diarrhea
  • Symptom - Vomiting

• General
  • Symptom - Death
  • Symptom - Parvovirus infection

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

1-47579663 The reporter, a pet owner, indicated her dog may have been exposed to a rodenticide containing the active ingredient diphacinone (present in free form or as sodium salt). On the day of initial contact with the registrant, the reporter indicated her 8-week-old, 5 pound, female, Chihuahua dog may have ingested an unknown amount of the product about 2 days earlier. At the time of the initial contact, the dog was vomiting and had bloody diarrhea. The reporter was advised to get immediate veterinary care as the dogs symptoms seem serious and might be due to ingestion of the product. On follow up call one day later, the reporter indicated she sought veterinary care for the dog where she was diagnosed with parvovirus and died. 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