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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0453

2. Registrant Information.

Registrant Reference Number: 1502103

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.

14-NOV-14

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

6. Date incident was first observed.

10-NOV-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. 12455-79

Product Name: Contrac All-Weather Blox

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

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected

1

5. Sex

Unknown

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

  • Blood
    • Symptom - Leukopenia
  • General
    • Symptom - Death
    • Symptom - Lethargy
  • Respiratory System
    • Symptom - Nose bleed

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 known exposure; speculated ingestion.

17. Provide any additional details about the incident

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

11/14/2014 7:45:52 AM A pest control operator (PCO) reported that a customer's dog who died suddenly on Tuesday Nov 11. He had limited information about the dog but stated it is an average sized Labrador retriever. The PCO visits the home monthly, and there are 6 Protecta bait stations containing 1 block of Contrac per station locked down in the basement. The dogs are not allowed in the basement and the stations were not broken into. The owners had been out of town and have multiple dogs. The Labrador was noted to be lethargic on Monday 11/10/14. Bloodwork was performed and showed low white blood cell count. The dog developed epistaxis at an unspecified time and died Tuesday, Nov 11, 2014. A necropsy was not performed and it is not known if any treatment was performed. The veterinarian suspected a possible toxin, and the dog owners are wondering if poisoning from the bait is possible. The PCO was most recently at the home 11/6/14. He knows the dog(s) did not get into the bait stations in the basement. The only way he can think that bait might have been consumed would be if the dog got into the PCO's bag unnoticed and quickly ate the old bait blocks that had been removed from the bait stations (6 blocks at most).


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.