Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-0575
2. Registrant Information.
Registrant Reference Number: 410996
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.
26-NOV-08
5. Location of incident.
Country: UNITED STATES
Prov / State: ARKANSAS
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 12455-69-3240
Product Name: Tomcat Ultra (Bait Tray)
- Active Ingredient(s)
- BROMADIOLONE
- Guarantee/concentration .005 %
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
Animal's Owner
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 )
0.17
7. Weight (provide a range if necessary )
5.00
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
- Nervous and Muscular Systems
- Respiratory System
- Symptom - Difficulty Breathing
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 has been no witnessed exposure but the potential for ingestion existed.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
11/26/2008 10:43:48 PM The caller reported that his puppy developed stiffness, labored breathing, and lethargy. He does not know if the dog ingested any of the product, but when he originally placed it under the house, the dog had shown interest in going under there and the tray is now completely empty. The dog died at home before he was able to seek veterinary care.
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.