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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1619

2. Registrant Information.

Registrant Reference Number: 1336240

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.

19-FEB-14

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

19-FEB-14

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. 12455-97-3240

Product Name: Rampage Pelleted Bait

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

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

No

9. Application Rate.

Unknown

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).

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

Catahoula leopard dog

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.6

7. Weight (provide a range if necessary )

45.00

lbs

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

  • Blood
    • Symptom - Bleeding
  • Gastrointestinal System
    • Symptom - Salivating excessively
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Rigidity
    • Symptom - Convulsions
    • Symptom - Abnormal posture
    • Symptom - Collapse

12. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Speculated ingestion of bait.

17. Provide any additional details about the incident

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

2/19/2014 11:34:30 AM A dog owner reported that his dog may have ingested product that had been placed in a barn; the barn door was left open the night of Feb 18, 2014 between 8:00 p.m. and 5:30 a.m. During this time, his dog had access to an unspecified number of 15gm place packs but he was unable to determine how many might be missing or were ingested by the dog. He reports having closed the barn door when leaving at 5:30 a.m., at which point the dog was asymptomatic. He arrived home 45 minutes ago to find the dog walking with a hunched posture and salivating. The dog then lunged up into the air several times and then collapsed, still salivating, and within 10 minutes the dog was convulsing and died; owner noted a pink tinge to the saliva on the dog's lip; within a few minutes the dog's body became stiff. He planned to take the dogs body to a veterinarian for possible tests to determine cause of death. No further information has been received as of May 20, 2014.


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.