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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6211

2. Registrant Information.

Registrant Reference Number: 1230494

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.

20-AUG-13

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

14-AUG-13

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: Hawk (non-specific)

  • 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

Toy Poodle

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

2.00

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Mouth Irritation
    • Specify - Ulceration of the tongue
  • General
    • Symptom - Death
    • Symptom - Hypothermia
  • Nervous and Muscular Systems
    • Symptom - Recumbent
  • Skin
    • Symptom - Pallor
  • General
    • Symptom - Vocalizing
  • Gastrointestinal System
    • Symptom - Inappropriate defecation
  • Skin
    • Symptom - Pale mucous membrane colour
    • Specify - gums were pale

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

No

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 Speculated ingestion.

17. Provide any additional details about the incident

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

8/20/2013 9:29:45 AM A pet owner reports that her dogs may have ingested an unknown amount of an unspecified Hawk product in the past 5-6 days. She found two of the puppies playing tug-o-war an empty bag of the product. On 8/18/13, one of those puppies was moaning and, the following day, was unable to stand. The dog was taken to a veterinarian and found to be hypothermic with a body temperature of 93.7 F on presentation. Additionally, his gums were pale and his tongue was ulcerated. The owner recalls soft stool was visible on the rectal thermometer and states the dog lost control of his bowels during the examination. The dog was tested for parvovirus and the result was negative. The puppy then passed away before any additional diagnostics or treatments could be performed. The puppy displayed no vomiting, diarrhea, coughing, or bleeding while at home. A necropsy was not performed. There are three other dogs in the home that may have been exposed to the product but all remain asymptomatic.


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.