Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0613

2. Registrant Information.

Registrant Reference Number: 1941587

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.

11-NOV-16

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

06-NOV-16

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. 12455-123-3240

Product Name: Tomcat Mouse Killer II (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

Other / Autre

specify Exotic

3. Breed

Rabbit

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

4.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

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?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify No known exposure.

17. Provide any additional details about the incident

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

11/11/2016 9:59:02 AM A pet owner called to report the death of his pet rabbit and to inquire if it was product related. On Nov 6, 2016 his pet rabbit was briefly allowed to roam free in a camper where the product had been previously placed. The pet owner is confident that was no direct product exposure, but the he is concerned that mice may have tracked residue around the camper and the rabbit may have had contact with that residue. The product had been inside a bait station. After being in the camper, the rabbit was brought back into the house where it was found dead 1-2 hours later. Per the pet owner, the rabbit has a history of flopping himself to the ground although its unclear exactly what this means. When the body was picked up from the floor, neck seemed limp but he did not indicate if the remainder of the body was also limp.

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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.