Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2157
2. Registrant Information.
Registrant Reference Number: 739863
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.
08-JAN-11
5. Location of incident.
Country: UNITED STATES
Prov / State: SOUTH CAROLINA
6. Date incident was first observed.
08-JAN-09
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
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
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
- Respiratory System
- Symptom - Shortness of breath
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify No witnessed exposure, based on speculation only.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1/8/2011 9:34:36 AM The caller wishes to report that his dog may have been exposed to this product approximately two years ago. While he is certain that the dog had no witnessed contact with the bait, he reports that his dog developed shortness of breath and died while the product was being used on his property. He refused to provide any information about the age, breed or weight of his dog nor other concurrent medical conditions which his dog may have had.
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.