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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1891

2. Registrant Information.

Registrant Reference Number: 1574294

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.

21-MAR-15

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

17-MAR-15

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. 12455-5-3240

Product Name: Tomcat All Weather Bait Chunx

  • Active Ingredient(s)
    • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
      • Guarantee/concentration .005 %

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

4

Units: oz (wts) / oz (pds)

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

Site: Res. - Out Home / Rés - à l'ext.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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

70.00

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 - Other
    • Specify - stomach being full of blood.
  • General
    • Symptom - Death
    • Symptom - Lethargy
    • Symptom - Weakness
  • Skin
    • Symptom - Pale mucous membrane colour

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?

Unknown

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 located on the property.

17. Provide any additional details about the incident

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

3/21/2015 Caller reports his daughter's dog died on 3/17/15 or 3/18/15 after being taken to its veterinarian for severe lethargy, weakness and pale gums. The dog passed away in the clinic and the veterinarian believes the cause of death to be a splenic mass rupture. Caller states there is a possibility the dog ingested 4 oz of the product 6-8 days prior to death. He states he placed 4oz behind a garbage can in his garage and just checked this morning to find all the product completely gone. Caller states a radiograph was performed (unknown view) about one month ago after the dog was experiencing upper respiratory symptoms and did not reveal any mass on the spleen but admits the spleen may not have been included in the image. He is wondering how to definitively know if the product was the cause of death. He does not know what emergency care or laboratory work up was done at the time of death and is unsure if necropsy has been performed. He did related that the veterinarian stated that the dogs stomach was full of blood.


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.