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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0455

2. Registrant Information.

Registrant Reference Number: 1507986

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.

24-NOV-14

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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.

Active(s)

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?

Unknown

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

Dachshund

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

9

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 - Bleeding
  • General
    • Symptom - Death
  • Respiratory System
    • Symptom - Wheezing

12. How long did the symptoms last?

Persisted until death

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

Yes

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 No direct exposure. Possible ingestion of dead rodents.

17. Provide any additional details about the incident

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

11/24/2014 2:50:59 PM The caller reports that her daughter's dog got into the barn on 11/16/14 and she thinks that he may have been exposed to some dead rodents because he died on 11/22/14. They have the product in their barn and on 11/16/14, the dog got into the barn and started wheezing. On 11/17/14, she took the dog to his veterinarian where he was treated with a steroid injection. The caller and her daughter thought that the dog may be allergic to the hay in the barn because the dog would often sneeze excessively when he returned home from their. On 11/20/14 she noticed more wheezing but the dog was otherwise fine. On 11/22/14, she was going to take him to another veterinarian due to persistent wheezing but she woke up to find that he had died. He had bloody discharge coming from his mouth. The caller is confident that the dog did not ingest any actual block of the product.


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.