Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7154

2. Registrant Information.

Registrant Reference Number: 1901211

Registrant Name (Full Legal Name no abbreviations): Bell Laboratories, Inc.

Address: 3699 Kinsman Blvd

City: Madison

Prov / State: WI

Country: USA

Postal Code: 53704

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

06-SEP-16

5. Location of incident.

Country: UNITED STATES

Prov / State: OREGON

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. 12455-122-3240

Product Name: Tomcat Rat Killer (pre-loaded resistant bait station)

• Active Ingredient(s)
  • BROMETHALIN
    • Guarantee/concentration .01 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

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

Belgian Tervuren

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

62.00

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
  • Symptom - Pain
  • Specify - Neck pain

• Blood
  • Symptom - Other
  • Specify - Unspecified blood loss

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Speculated oral exposure without witnessed or confirmed ingestion.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

9/6/2016 Caller is very difficult to gather information from and provided contradictory information several times during the report. She is concerned that the product was placed around her property without her knowledge but could not articulate how she discovered the product or when it may have been placed there. She also can not confirm ingestion of the product by each dog prior to their death. She has two dogs a Belgian Tervuren and a second for which she did not provide a breed. The first dog acutely developed pain in his neck. At an unknown point in time following this, the dog died and was necropsied. The cause of death was due to massive blood loss, reason unknown by the caller. We were unable to determine if the dog was examined by a veterinarian or if any medical treatment was provided at any point. Her second dog died 12 hours after the first. The symptoms were said to be similar to that of the first dog, however it was difficult to gather specifics on this. The pet owner elected to have the second dog euthanized due to the symptoms. Treatments prior to death are also unknown. We explained the active ingredients and their mechanism of action on the central nervous system. Blood loss would not be expected with this product.

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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

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

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

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Neck pain

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Euthanised / Euthanasie

16. How was the animal exposed?

Other / Autre

specify Speculated oral exposure without witnessed or confirmed ingestion.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

9/6/2016 Caller is very difficult to gather information from and provided contradictory information several times during the report. She is concerned that the product was placed around her property without her knowledge but could not articulate how she discovered the product or when it may have been placed there. She also can not confirm ingestion of the product by each dog prior to their death. She has two dogs¿¿¿¿¿¿a Belgian Tervuren and a second for which she did not provide a breed. The first dog acutely developed pain in his neck. At an unknown point in time following this, the dog died and was necropsied. The cause of death was due to massive blood loss, reason unknown by the caller. We were unable to determine if the dog was examined by a veterinarian or if any medical treatment was provided at any point. Her second dog died 12 hours after the first. The symptoms were said to be similar to that of the first dog, however it was difficult to gather specifics on this. The pet owner elected to have the second dog euthanized due to the symptoms. Treatments prior to death are also unknown. We explained the active ingredients and their mechanism of action on the central nervous system. Blood loss would not be expected with this product.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Major

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.