Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6425

2. Registrant Information.

Registrant Reference Number: 1647853

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.

15-JUL-15

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

12-JUL-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)

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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 III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Golden Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

55.00

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

• General
  • Symptom - Death
  • Symptom - Weakness

• Gastrointestinal System
  • Symptom - Vomiting

• Respiratory System
  • Symptom - Sneezing
  • Symptom - Other
  • Specify - Unspecified breathing problems

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 known exposure.

17. Provide any additional details about the incident

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

On 7/15/2015 a supervisor and pest control operator (PCO) at a pest control business reported that a dog belonging to one of his customers had died. The most recent application of rodenticide at the clients home was on 6/23/15. The pet owner stated that, on 7/12/15, his dog developed sneezing and breathing problems. The dog was examined by a veterinarian on 7/13/15 because she had become weak and was vomiting. Blood tests were preformed but the results were not communicated to the PCO. The dog passed away on the evening of 7/13/15 and was cremated the following day. The PCO went to the customers home on 7/16/15 and, with the pet owner, inspected each of the eight bait stations on the property. The bait stations were in an area the dog had access to but none of the stations were compromised, the bait inside them was still intact, there were no bite marks on any of the stations, no missing bait, and the bait stations were still anchored to the ground. The pet owner was unaware of any dog feces that contained indicator dyes.

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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.