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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3946

2. Registrant Information.

Registrant Reference Number: 627598

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.

04-MAY-10

5. Location of incident.

Country: UNITED STATES

Prov / State: IOWA

6. Date incident was first observed.

04-MAY-10

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. 12455-79-3240

Product Name: Tomcat Ultra Block Bait

  • 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. - 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Miniature Schnauzer

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

15.00

lbs

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

  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Death
    • Symptom - Weakness
  • Cardiovascular System
    • Symptom - Abnormally slow heart rate
  • Skin
    • Symptom - Pallor

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

Day(s) / Jour(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify No known exposure.

17. Provide any additional details about the incident

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

5/4/2010 11:28:14 AM The caller used this product in his home and did find one rat that was killed by the product. His dog had access to the dead rat but the caller claims that the dog did not have access to the bait. The dog developed anorexia and was diagnosed with a viral infection by a veterinarian on 5/4/10. The veterinarian performed diagnostics (a complete blood count, chemistry profile and blood gas analysis). There was no mention of coagulation testing. The dog was discharged from the clinic and it is not know if treatments were performed. One 5/6/10 the dog presented to an emergency room for weakness. On exam, it was found that the dog had a very low heart rate and was pale. He was treated with intravenous fluids, unknown medications and, ultimately, given CPR. CPR was unsuccessful and the dog died in the clinic. A necropsy was not performed and a cause of death was not defined.


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.