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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: 2017-0607

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 1921335

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

Adresse: 3699 Kinsman Blvd

Ville: Madison

État: WI

Pays: USA

Code postal /Zip: 53704

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.

08-OCT-16

5. Lieu de l'incident.

Pays: UNITED STATES

État: GEORGIA

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. 12455-143-3240

Nom du produit: Tomcat with Bromethalin Place Pacs

  • Matière active
    • BROMETHALIN
      • Garantie/concentration .01 %

7. b) Type de formulation.

Appât

Renseignments sur l'application

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

Oui

9. Dose d'application.

Inconnu

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

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

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?

Non

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Miniature Schnauzer

4. Nombre d'animaux touchés

4

5. Sexe:

Homme

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

2

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

10.00

lbs

8. Voie(s) d'exposition:

Orale

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 gastro-intestinal
    • Symptôme - Anorexie
    • Symptôme - Salivation
  • Systèmes nerveux et musculaire
    • Symptôme - Agitation

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Inconnu

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

Unknown/Inconnu

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

Accidental ingestion/Ingestion accident.

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

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

10/8/2016 11:28:30 AM The contents of 4 pound pail of product was placed under a rented mobile home on approximately October 1, 2016. The tenant has 12 dogs who were thought to have ingested an unknown amount of bait from beneath the mobile home. The dog owner has seen evidence the product indicator dye in dog feces in her yard but does not know exactly which dogs ingested the product. One dog died on Oct 7, 2016 after exhibiting anorexia, malaise, shaking, and loss of her hind limbs. This do was seen by a veterinarian the morning of Oct 7, given fluids (unknown route), antibiotics, and other unspecified treatments. Blood work was performed but the pet owner did not know the results. The veterinarian did not appear to have provided a diagnosis but advised the owner the dogs prognosis was grave. This dog had a history of developing hypocalcemia while pregnant and weaned puppies a few weeks prior to death. Three additional dogs are symptomatic, the first of which is exhibiting drooling, anorexia, and shaking. The second dog is reportedly acting funny (interpreted as malaise) and does not appear to hear when you talk to her; she is also depressed, won't hold her head up very often, is yawning, and licking at her mouth frequently. The third dog, which is also pregnant, has exhibited dry-heaving and is acting very timid and scared which is abnormal. Neither the pet owner nor landlord could immediately identify the product used as the pail/container had been thrown away. The landlord returned to the place of purchase and believes this is the product she originally purchased.


À être déterminé par le titulaire

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

Modérée

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Miniature Schnauzer

4. Nombre d'animaux touchés

4

5. Sexe:

Femme

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

4

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

10.00

lbs

8. Voie(s) d'exposition:

Orale

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

  • General
    • Symptôme - Se lèche
    • Specify - Licking lips
    • Symptôme - Autre
    • Specify - Yawning
    • Symptôme - Malaise
  • Systèmes nerveux et musculaire
    • Symptôme - Dépression
    • Symptôme - Posture anormale
    • Specify - Will not hold head up often
  • Oreille
    • Symptôme - Autre
    • Specify - Does not appear to hear when you talk to her

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Inconnu

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

Unknown/Inconnu

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

Accidental ingestion/Ingestion accident.

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

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

10/8/2016 11:28:30 AM The contents of 4 pound pail of product was placed under a rented mobile home on approximately October 1, 2016. The tenant has 12 dogs who were thought to have ingested an unknown amount of bait from beneath the mobile home. The dog owner has seen evidence the product indicator dye in dog feces in her yard but does not know exactly which dogs ingested the product. One dog died on Oct 7, 2016 after exhibiting anorexia, malaise, shaking, and loss of her hind limbs. This do was seen by a veterinarian the morning of Oct 7, given fluids (unknown route), antibiotics, and other unspecified treatments. Blood work was performed but the pet owner did not know the results. The veterinarian did not appear to have provided a diagnosis but advised the owner the dogs prognosis was grave. This dog had a history of developing hypocalcemia while pregnant and weaned puppies a few weeks prior to death. Three additional dogs are symptomatic, the first of which is exhibiting drooling, anorexia, and shacking. The second dog is reportedly acting funny (interpreted as malaise) and does not appear to hear when you talk to her; she is also depressed, won't hold her head up very often, is yawning, and licking at her mouth frequently. The third dog, which is also pregnant, has exhibited dry-heaving and is acting very timid and scared which is abnormal. Neither the pet owner nor landlord could immediately identify the product used as the pail/container had been thrown away. The landlord returned to the place of purchase and believes this is the product she originally purchased.


À être déterminé par le titulaire

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

Mineure

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Miniature Schnauzer

4. Nombre d'animaux touchés

4

5. Sexe:

Femme

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

1

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

10.00

lbs

8. Voie(s) d'exposition:

Orale

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 gastro-intestinal
    • Symptôme - Avoir des haut-le-coeur
  • General
    • Symptôme - Comportement anormal
    • Specify - scared

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Inconnu

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

Unknown/Inconnu

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

Accidental ingestion/Ingestion accident.

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

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

10/8/2016 11:28:30 AM The contents of 4 pound pail of product was placed under a rented mobile home on approximately October 1, 2016. The tenant has 12 dogs who were thought to have ingested an unknown amount of bait from beneath the mobile home. The dog owner has seen evidence the product indicator dye in dog feces in her yard but does not know exactly which dogs ingested the product. One dog died on Oct 7, 2016 after exhibiting anorexia, malaise, shaking, and loss of her hind limbs. This do was seen by a veterinarian the morning of Oct 7, given fluids (unknown route), antibiotics, and other unspecified treatments. Blood work was performed but the pet owner did not know the results. The veterinarian did not appear to have provided a diagnosis but advised the owner the dogs prognosis was grave. This dog had a history of developing hypocalcemia while pregnant and weaned puppies a few weeks prior to death. Three additional dogs are symptomatic, the first of which is exhibiting drooling, anorexia, and shacking. The second dog is reportedly acting funny (interpreted as malaise) and does not appear to hear when you talk to her; she is also depressed, won't hold her head up very often, is yawning, and licking at her mouth frequently. The third dog, which is also pregnant, has exhibited dry-heaving and is acting very timid and scared which is abnormal. Neither the pet owner nor landlord could immediately identify the product used as the pail/container had been thrown away. The landlord returned to the place of purchase and believes this is the product she originally purchased.


À être déterminé par le titulaire

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

Mineure

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Miniature Schnauzer

4. Nombre d'animaux touchés

4

5. Sexe:

Femme

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

4

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

10.00

lbs

8. Voie(s) d'exposition:

Orale

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 gastro-intestinal
    • Symptôme - Anorexie
    • Symptôme - Salivation
  • General
    • Symptôme - Mort
  • Systèmes nerveux et musculaire
    • Symptôme - Réveil difficile
    • Specify - Loss of use of hind limbs
    • Symptôme - Agitation
  • General
    • Symptôme - Malaise

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?

Non

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

Inconnu

15. Issue de l'incident

Mort

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

Accidental ingestion/Ingestion accident.

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

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

10/8/2016 11:28:30 AM The contents of 4 pound pail of product was placed under a rented mobile home on approximately October 1, 2016. The tenant has 12 dogs who were thought to have ingested an unknown amount of bait from beneath the mobile home. The dog owner has seen evidence the product indicator dye in dog feces in her yard but does not know exactly which dogs ingested the product. One dog died on Oct 7, 2016 after exhibiting anorexia, malaise, shaking, and loss of use of her hind limbs. This do was seen by a veterinarian the morning of Oct 7, given fluids (unknown route), antibiotics, and other unspecified treatments. Blood work was performed but the pet owner did not know the results. The veterinarian did not appear to have provided a diagnosis but advised the owner the dogs prognosis was grave. This dog had a history of developing hypocalcemia while pregnant and weaned puppies a few weeks prior to death. Three additional dogs are symptomatic, the first of which is exhibiting drooling, anorexia, and shacking. The second dog is reportedly acting funny (interpreted as malaise) and does not appear to hear when you talk to her; she is also depressed, won't hold her head up very often, is yawning, and licking at her mouth frequently. The third dog, which is also pregnant, has exhibited dry-heaving and is acting very timid and scared which is abnormal. Neither the pet owner nor landlord could immediately identify the product used as the pail/container had been thrown away. The landlord returned to the place of purchase and believes this is the product she originally purchased.


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

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.