Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0888
2. Registrant Information.
Registrant Reference Number: 882976
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.
11-NOV-11
5. Location of incident.
Country: UNITED STATES
Prov / State: MASSACHUSETTS
6. Date incident was first observed.
11-OCT-11
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. Unknown
Product Name: Bromethalin (non-specific)
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
Cat / Chat
3. Breed
DSH
4. Number of animals affected
1
5. Sex
Male
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
- General
- Symptom - Death
- Symptom - Pain
- Liver
- Symptom - Other
- Specify - Unspecified hepatic abnormality
- Blood
- Symptom - Anemia
- Specify - unspecified "red blood cell deficiency"
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?
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 witnessed exposure, based upon speculation only.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
11/11/2011 1:00:30 PM
The callers cat approximately one month ago following an unspecified red blood cell deficiency. The cat also had a history of hepatic (liver) disease and possible osteoarthritis in his hind limbs. She recently found this product placed outside her property and is wondering if the cat could have died from this. There is no known exposure.
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.