Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-8686

2. Registrant Information.

Registrant Reference Number: 186825

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.

14-MAY-07

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

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. 12455-89-3240

Product Name: Jaguar Bait Chunx12455-89-3240

• Active Ingredient(s)
  • BRODIFACOUM
    • Guarantee/concentration .005 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 12455-68-3240

Product Name: Hawk Pre-Baited Bait Station12455-68-3240

• Active Ingredient(s)
  • BROMADIOLONE
    • Guarantee/concentration .005 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 12455-95-3240

Product Name: Rampage All Weather Bait Chunx12455-95-3240

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

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

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

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

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

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?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify There is no known exposure to the product.

17. Provide any additional details about the incident

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

5/14/2007 1:55:01 PMThe caller states he is being accused of accidentally poisoning his neighbor¿s dog. His neighbor is claiming their dog ate some mice that ingested the poison that the caller had set out. There is a fence between the yards and the neighbor¿s dog is not able to get into his yard. The dog¿s body will be necropsied. The caller does not know what the dog¿s symptoms have been prior to death. The active ingredient is a long-acting anticoagulant. Evidence of death via this type of toxin would be verifiable on necropsy. Death due to relay toxicity in dogs due to this particular type of toxin is unlikely as the dog would need to be eating many, many mice on a consistent basis for a very long period of time.

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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