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Sécurité des produits de consommation

Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2014-1407

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: PROSAR case: 1-36379674

Nom du titulaire (nom légal complet, aucune abbréviation): HACCO, Inc.

Adresse: 110 Hopkins Drive

Ville: Randolph

État: Wisconsin

Pays: USA

Code postal /Zip: 53956

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

06-MAR-14

5. Lieu de l'incident.

Pays: UNITED STATES

État: TEXAS

6. Date de la première observation de l'incident.

Inconnu

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 612282-12

Nom du produit: Ramik Bars All-Weather Rat and Mouse Killer

  • Matière active
    • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
      • Garantie/concentration .005 %

7. b) Type de formulation.

Appât

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Inconnu

9. Dose d'application.

10. Site d'application (choisir tout ce qui s'applique).

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Unknown

4. Nombre d'animaux touchés

1

5. Sexe:

Homme

6. Âge (fournir un ordre de grandeur si nécessaire)

0.2

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

  • Système respiratoire
    • Symptôme - Autre
    • Specify - sneezing blood
  • General
    • Symptôme - Mort

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Oui

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Inconnu

14. b) Combien de temps l'animal était-il hospitalisé?

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser No exposure witnessed

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

1-36379674 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that her 20 pound, male mixed breed dog started sneezing one day prior to initial contact with the registrant and on the day of contact the dog was lethargic and not eating. No exposure to the registrant product was witnessed and there was no evidence of missing product but the reporter was concerned that her pets symptoms might be from exposure to this product. The reporter was advised that there are numerous possible causes for the described symptoms and immediate veterinary care was recommended to determine an underlying cause and appropriate treatment. The reporter was further advised that if symptoms were from exposure to this product the veterinarian could treat the dog with the antidote, vitamin K1. The reporter then stated that about 3 to 4 weeks prior to her call her 10 week old unvaccinated puppy (Subform III #1) passed away. No exposure to the registrant product was witnessed but the reporter indicated that this puppy was sneezing blood for about 2 days. They brought the puppy to the veterinarian where it died. Per the reporter the veterinarian did not know the cause of the puppys death. A follow-up call regarding the reporter s male, 20 pound dog was made one day after the initial call. The reporter indicated that she did take her 20 pound, male mixed breed dog to the veterinarian where a PT test was run and found to be normal. The reporter then stated that this dog had recently eaten a dead bird and she thought its symptoms might be due to ingestion of the bird. The veterinarian had given the dog some unknown medications and it was now doing better. No further information is available.


À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

1-36379674 - The reporter, a pet owner, indicated that her dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that her 20 pound, male mixed breed dog started sneezing one day prior to initial contact with the registrant and on the day of contact the dog was lethargic and not eating. No exposure to the registrant product was witnessed and there was no evidence of missing product but the reporter was concerned that her pets symptoms might be from exposure to this product. The reporter was advised that there are numerous possible causes for the described symptoms and immediate veterinary care was recommended to determine an underlying cause and appropriate treatment. The reporter was further advised that if symptoms were from exposure to this product the veterinarian could treat the dog with the antidote, vitamin K1. The reporter then stated that about 3 to 4 weeks prior to her call her 10 week old unvaccinated puppy (Subform III #1) passed away. No exposure to the registrant product was witnessed but the reporter indicated that this puppy was sneezing blood for about 2 days. They brought the puppy to the veterinarian where it died. Per the reporter the veterinarian did not know the cause of the puppys death. A follow-up call regarding the reporter s male, 20 pound dog was made one day after the initial call. The reporter indicated that she did take her 20 pound, male mixed breed dog to the veterinarian where a PT test was run and found to be normal. The reporter then stated that this dog had recently eaten a dead bird and she thought its symptoms might be due to ingestion of the bird. The veterinarian had given the dog some unknown medications and it was now doing better. No further information is available.