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Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2013-2039

2. Registrant Information.

Registrant Reference Number: 1136206

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 12455-120-3240

Product Name: Tomcat Mouse Killer I (refillable resistant bait station)

• Active Ingredient(s)
  • BROMETHALIN
    • Guarantee/concentration .01 %

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

No

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Foaming at mouth

• General
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

3/20/2013 Police investigator reports that they are investigating the death of a approximately (age) y/o male found dead in a bedroom at a friend's home on March 20, 2013. He had recently been separated from his wife and was staying with friends at the time of his death. He appears to have been dead for about 5 hrs based on investigation. Little else is known about his past medical history other than to have noted that he may have had a history of depression to some degree. He was last seen the night prior at about 10pm by friends he was staying with. At that time he appeared to be in good health. He was heard to have been snoring heavily last night by friends in the house and found dead this morning while lying in his bed. The only sign of note on the body was that he appeared to have an orange colored sputum in his mouth.

To be determined by Registrant

14. Severity classification.

Death

15. 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. This product appears to be implicated in this case simply based on it being found in the general location of the patient upon his death. Ascribing any type of causality with this rodenticide and the patients death is highly speculative. There is no clinical or forensic information available that would suggest that this patient died of bromethalin toxicity. Status update: On 4/19/13 the police investigator reported follow-up information for this case. He indicated that , per their investigation and medical examiner's report, it was determined that the death was due to a drug overdose. While he does not recall the specific drug, he stated that the death was found not to be related to this product.