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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1594

2. Registrant Information.

Registrant Reference Number: 1069920

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.

06-NOV-12

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

06-NOV-12

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) (discontinued)

  • Active Ingredient(s)
    • BROMADIOLONE
      • Guarantee/concentration .005 %

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

Corgi (Welsh, Pembroke or Cardigan)

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

25.00

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

  • General
    • Symptom - Death
    • Symptom - Malaise

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?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

11/6/2012 10:14:21 PM The callers dog ingested 4 oz of bait on Nov 6, 2012. Following ingestion, vomiting was induced within 60 min and some bait was recovered. The dog remained asymptomatic and the pet owner denied the possibility of previous rodenticide exposure. 11/19/2012 10:55:20 AM The pet owner called back with an update to his case. On Nov 16, 2012 the caller realized that his dog had gained access to and ingested an additional 8 ounces of bait between Nov 11 and Nov 14, 2013. The dog also runs free on their horse farm and has the opportunity to ingest any number of things, including anticoagulant rodenticides. The dog became ill (unspecified clinical signs) on Nov 14, 2012 and subsequently died in the veterinary clinic on Nov 15, 2012. Anticoagulant rodenticide poisoning was suspected but not confirmed and it is unclear as to whether or not any treatment was provided. There is a second dog in the home who has undergone coagulation testing and the results were normal


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.