Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-8688
2. Registrant Information.
Registrant Reference Number: 189231
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.
21-MAY-07
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW MEXICO
6. Date incident was first observed.
21-MAY-07
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 12455-39-3240
Product Name: TOMCAT Vitamin D3 Mouse Poison12455-39-3240
- Active Ingredient(s)
- CHOLECALCIFEROL
- Guarantee/concentration .075 %
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. - In Home / Rés. - à l'int. 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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
50
lbs
8. Route(s) of exposure
Oral
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
- Nervous and Muscular Systems
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
1
Hour(s) / Heure(s)
15. Outcome of the incident
Died
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
5/21/2007 12:50:31 PM Caller a DVM who stated that a dog ingested at least 0.75 oz (maybe more) of the product 15 minutes ago. Vomiting was induced and bait was seen in emesis. The toxic dose of this product is 18.7g. Advised DVM that we agree with the decontamination performed. Would recommend that you keep him in the hospital for the day and perform the following: multiple dose activated charcoal per day, close monitoring of serum calcium, phosphorus, BUN and creatinine, urinalysis and urine specific gravity. Follow up on 5/21/2007 at 12:55:01 PM from the DVM: The dog had a grand mal seizure and died. Caller wondering if acute neurological symptoms are seen with this product.Acute neurological symptoms are not expected with this toxin. This toxin causes elevated serum calcium and this takes 24-48 hours to develop.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here