Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3878

2. Registrant Information.

Registrant Reference Number: 1584749

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.

Human

Domestic Animal

4. Date registrant was first informed of the incident.

08-APR-15

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 12455-79

Product Name: Contrac All-Weather Blox

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

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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. - 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?

Yes

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Stomach pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Other

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the chicken owner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait as she saw blue-gray material in the chickens feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the call. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

To be determined by Registrant

14. Severity classification.

Minor

15. 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.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Stomach pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Other

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

To be determined by Registrant

14. Severity classification.

Minor

15. 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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Silky

4. Number of animals affected

5

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

3

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

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Death
  • Symptom - Swelling

12. How long did the symptoms last?

Persisted until death

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 No witnessed exposure; speculated ingestion.

17. Provide any additional details about the incident

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

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens¿¿¿¿¿¿ feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

---

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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Americana

4. Number of animals affected

5

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

3

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

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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 No witnessed exposure; speculated ingestion.

17. Provide any additional details about the incident

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

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens¿¿¿¿¿¿ feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

---

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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Unknown

4. Number of animals affected

5

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

3

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

• General
  • Symptom - Swelling

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Death

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?

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 witnessed exposure; speculated ingestion.

17. Provide any additional details about the incident

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

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens¿¿¿¿¿¿ feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

---

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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

unknown

4. Number of animals affected

5

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

3

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

• Gastrointestinal System
  • Symptom - Bloating

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Specify - Unable to walk

• Skin
  • Symptom - Cyanosis

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?

No

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify No witnessed exposure; speculated ingestion of product.

17. Provide any additional details about the incident

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

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens¿¿¿¿¿¿ feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

---

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Major

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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Unknown

4. Number of animals affected

5

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

3

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

• Gastrointestinal System
  • Symptom - Abnormal feces colour
  • Symptom - Diarrhea

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?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify Suspected ingestion of bait.

17. Provide any additional details about the incident

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

4/13/2015 A pest control operator placed blocks of the product in protective bait stations near a chicken coop. Within 2-4 weeks of bait placement, the homeowner reported that 3 chickens had died from unknown causes although she suspects the chickens were poisoned by eating the bait and reports she saw blue-gray material in the chickens¿¿¿¿¿¿ feces. One chicken passed away suddenly and the other two developed swelling and stopped eating prior to death. A fourth chicken became ill as evidenced by bloating, difficulty walking which progressed to being unable to walk, and the development of a blue coloration to her face and comb. A fifth chicken developed blue and yellow diarrhea. Finally, the caller remarked that there is a considerable amount of blue and yellow feces in the chicken coop. Additionally, the chicken owner reported that she and her son eat the eggs from these hens and have both experienced diarrhea and stomach aches over the past 3 months and are concerned that they may have secondary poisoning. The caller saw her physician and had either a PT or INR test performed but did not have the results at the time of the calls. She noted that it was too expensive to have a veterinarian examine or treat her hens and was unlikely to seek veterinary care.

---

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here