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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-3387
2. Registrant Information.
Registrant Reference Number: 2211488
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.
03-APR-185. Location of incident.
Country: UNITED STATES
Prov / State: ILLINOIS
6. Date incident was first observed.
30-MAR-18Product 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. 12455-80-3240
Product Name: Tomcat All Weather Bait Chunx
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .005 %
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
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
Chihuahua
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
4.00
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
- Gastrointestinal System
- Symptom - Gagging
- General
- Symptom - Death
- Respiratory System
- Symptom - Choking
- Symptom - Coughing
- Symptom - Difficulty Breathing
- General
- Symptom - Bad breath
12. How long did the symptoms last?
Persisted until death
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 speculated ingestion of exposed rodent
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
4/3/2018 2:22:58 PM A pet owner reported that she placed the product on her property the previous winter. On or around March 30 żżżżżż 31, 2018 the owner found a dead mouse behind the couch that may have been chewed on by one of her dogs, though no ingestion was witnessed. The dogs had no direct access to the bait. Approximately 1-2 days later the female dog developed difficulty breathing, had malodorous breath, and was coughing and gagging. On April 3, 2018 the female dog died at home. No veterinary intervention was reportedly sought. The owner also noted her male dog was very lethargic. Veterinary evaluation was recommended for the male dog. No further information was received in this case.
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
Chihuahua
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
8
7. Weight (provide a range if necessary )
4.00
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 - Lethargy
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
specify speculated ingestion of exposed rodent
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
4/3/2018 2:22:58 PM A pet owner reported that she placed the product on her property the previous winter. On or around March 30-31, 2018 the owner found a dead mouse behind the couch that may have been chewed on by one of her dogs, though no ingestion was witnessed. The dogs had no direct access to the bait. Approximately 1-2 days later the female dog developed difficulty breathing, had malodorous breath, and was coughing and gagging. On April 3, 2018 the female dog died at home. No veterinary intervention was reportedly sought. The owner also noted her male dog was very lethargic. Veterinary evaluation was recommended for the male dog. No further information was received in this case.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
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.
