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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-4958

2. Registrant Information.

Registrant Reference Number: 1817410

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-MAY-16

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

07-MAY-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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Contrac (non-specific)

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

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

Great Dane

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

120.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Fecal incontinence
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Convulsions
  • Blood
    • Symptom - Bleeding

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 known direct exposure.

17. Provide any additional details about the incident

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

5/7/2016 2:35:58 PM A gentleman from Chemtrec received a report of a fatality from a pest control operator (PCO) and wanted to report it to the manufacturer. Chemtrec reports a PCO called them regarding a possible rodenticide exposure. The PCO used several products at a private residence between 9am and 10:30am EST on 5/7/16, including Contrac Blox in bait stations. Chemtrec does not know if the bait stations were disturbed or how many bait stations were placed. The dog was on the outside deck at the time of the appointment. 30 minutes after the PCO left, the dog began bleeding from the mouth, convulsing and losing control of its bowels. The dog died after these clinical signs occurred. The dog's body will be necropsied. Patient information: The dog was a 4 year old Great Dane weighing 120-130 pounds. The reporter does not know the dog's health history or know if the dog had been previously exposed to the active ingredient. No additional follow-up information was received from Chemtrec or the PCO.


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.