Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-2659

2. Registrant Information.

Registrant Reference Number: 1750684

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.

07-JAN-16

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

02-JAN-16

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. 12455-89

Product Name: Final All-Weather Blox

• Active Ingredient(s)
  • BRODIFACOUM
    • 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. - 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shorthaired Pointer

4. Number of animals affected

3

5. Sex

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

54.00

lbs

8. Route(s) of exposure

Oral

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 - Anemia
  • Symptom - Coagulopathy
  • Specify - Other coagulopathy

• General
  • Symptom - Death

• Eye
  • Symptom - Swollen eye

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Lameness
  • Symptom - Other
  • Specify - Shoulder pain

• Eye
  • Symptom - Other
  • Specify - hematoma in the eye

• General
  • Symptom - Swelling

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Specify - limping

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?

Yes

14. b) How long was the animal hospitalized?

24

Hour(s) / Heure(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

1/7/2016 9:49:10 AM Caller states that her landlord placed Final All-Weather Blox in the rafters of the basement 3 months ago in her home unbeknownst to her and one of her 3 dogs passed away on 06 January 2016. On 01/02/16 the dog had started limping on the right leg. He daughter, who is a veterinary technician student came to the home to look at the leg and foot to determine if the dog had been injured. The dog exhibited pain in the shoulder during palpation. They bandaged the shoulder and applied ice and heat incase of an injury as the veterinary clinic was closed. On 01/03 she noticed that the dog's right eye seemed swollen and upon inspection, saw what appeared to be a blood blister on the tissue of the third eye lid and the whole top part of the eye lid. The dog was also very lethargic. At this time the owner states that she was still unaware that the rodenticide had been placed in the home at all. First thing Monday morning 01/04/16 owner brought the dog to the veterinarian. They diagnosed a large hematoma on the eye and sent home a steroid ointment to apply to the area. On 01/05/16 the whole right side of the face was swollen and the eye continued swell. Owner also noticed that there was a very soft bulge on the left side of the dog's abdomen. They rushed the dog back to the hospital. The clinic ran a CBC and blood screen and determined that the dog was anemic and suspected that she could have bee exposed to or ingested a rodenticide. They did a fine needle aspiration on the bulge on the left side abdomen and immediately the dog developed bleeding. They hospitalized the dog, placing her on IV fluids and started Vit K 1. The clinic did run a clot time and the results were more than 5 minutes prolonged. So far as the owner is aware, clinic did not attempt a transfusion. On 01/06/16 the veterinarian called owner to let her know that the dog had not made it through the night. Follow-up information obtained on 11 January 2016: There are two other dogs in the home. These were both brought to the veterinarian on 1/8/2016 to have a clotting/PTT test done. Both dogs were asymptomatic but their test results were 0.5 seconds greater than normal. To be cautious, the veterinarian prescribed both dogs 4 weeks of K1.

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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.