Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7155

2. Registrant Information.

Registrant Reference Number: 1901371

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-SEP-16

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

03-SEP-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. 12455-80-3240

Product Name: Tomcat All Weather Bait Chunx

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

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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

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

Rat Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

Unknown

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 - Other
  • Specify - Spitting blood

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Wobbly

• Gastrointestinal System
  • Symptom - Gagging

• Skin
  • Symptom - Other
  • Specify - Unspecified sore on the neck

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 Speculated ingestion of poisoned rodents.

17. Provide any additional details about the incident

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

9/7/2016 The caller reports that her 1 year old Rat Terrier dog showed signs of gagging, spitting blood, and being wobbly before dying on 9/3/16. Just prior, the owner had also noticed a sore on her neck. The pet owner is uses the product on her property but keeps all baits within bait stations, regardless, she is worried that her dogs may have ingested rodents that had consumed the product although she has not observed this. In addition to the dog that passed away, she has 3 more dogs that are constantly kenneled. Two of them are acting wobbly and weak, similar to the first. The owner does not know the weights of any of the dogs and cannot estimate a weight. Immediate veterinary intervention was recommended.

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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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.7

7. Weight (provide a range if necessary )

Unknown

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 - Weakness

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Wobbly

12. How long did the symptoms last?

Unknown / Inconnu

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?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify Speculated ingestion of poisoned rodents.

17. Provide any additional details about the incident

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

9/7/2016 The caller reports that her 1 year old Rat Terrier dog showed signs of gagging, spitting blood, and being wobbly before dying on 9/3/16. Just prior, the owner had also noticed a sore on her neck. The pet owner is uses the product on her property but keeps all baits within bait stations, regardless, she is worried that her dogs may have ingested rodents that had consumed the product although she has not observed this. In addition to the dog that passed away, she has 3 more dogs that are constantly kenneled. Two of them are acting wobbly and weak, similar to the first. The owner does not know the weights of any of the dogs and cannot estimate a weight. Immediate veterinary intervention was recommended.

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To be determined by Registrant

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

Moderate

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

Dog / Chien

3. Breed

Boston Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

Unknown

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 - Weakness

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Wobbly

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

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 Speculated ingestion of poisoned rodents.

17. Provide any additional details about the incident

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

9/7/2016 The caller reports that her 1 year old Rat Terrier dog showed signs of gagging, spitting blood, and being wobbly before dying on 9/3/16. Just prior, the owner had also noticed a sore on her neck. The pet owner is uses the product on her property but keeps all baits within bait stations, regardless, she is worried that her dogs may have ingested rodents that had consumed the product although she has not observed this. In addition to the dog that passed away, she has 3 more dogs that are constantly kenneled. Two of them are acting wobbly and weak, similar to the first. The owner does not know the weights of any of the dogs and cannot estimate a weight. Immediate veterinary intervention was recommended.

---

To be determined by Registrant

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

Moderate

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.