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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-3442

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-47203207

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.

21-FEB-17

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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. 61282-46

Product Name: RAMIK GREEN KILLS RATS & MICE FISH FLAVORED WEATHER-RESISTANT RODENTIC

  • 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

Pit Bull Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.67

7. Weight (provide a range if necessary )

Unknown

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
  • Gastrointestinal System
    • Symptom - Bloody vomit
  • Respiratory System
    • Symptom - Coughing
  • Gastrointestinal System
    • Symptom - Oral hemorrhage

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

1-47203207 - The reporter, a pet owner, indicated his 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 his 8-month-old, male, Pit Bull Terrier dog of unknown weight might have eaten an unknown amount of the product at an unknown date. At the time of the call, the dog had bloody vomit. The reporter was advised to get immediate veterinary attention for the dog as the dogs condition might be critical and the symptom could be due to product ingestion. On follow-up call one day later, the reporter indicated no further bleeding was seen, but the dog was now coughing. The reporter indicated he was taking the dog to a veterinarian that day. On follow-up call six days after the day of initial contact, the reporter indicated he had taken the dog to a veterinarian and got treatment, but the dog developed bleeding from the mouth three days after the day of initial contact and died in the car on the way to the veterinarian. 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