Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-3947
2. Registrant Information.
Registrant Reference Number: 636979
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.
25-MAY-10
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
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. CA50003-AA
Product Name: PCQ Pelleted Rodent Bait
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
- Guarantee/concentration .01 %
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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
Border Collie
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
45.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Death
- Symptom - Lethargy
- Nervous and Muscular Systems
- Symptom - Difficulty getting up
- Specify - Down animal, unable to rise
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?
No
14. b) How long was the animal hospitalized?
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
5/25/2010 11:23:04 AM The caller¿s dog became acutely lethargic, unable to stand and died within 8-12 hours of the onset of clinical signs. Three weeks prior to the dog¿s clinical signs, the caller had placed this product in his the yard. The dog owner had not witnessed the dog getting into the product and the original placement of the product appears to be fully intact. Veterinary care was not sought.
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.