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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0616

2. Registrant Information.

Registrant Reference Number: 1964108

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.

21-DEC-16

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

6. Date incident was first observed.

21-DEC-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. 12455-83-3240

Product Name: Tomcat Rat & Mouse Bait Place Pac (discontinued)

  • Active Ingredient(s)
    • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
      • 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. - 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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Pit Bull Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.3

7. Weight (provide a range if necessary )

7.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • General
    • Symptom - Lethargy

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 Potential ingestion of this or other pesticides

17. Provide any additional details about the incident

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

12/21/2016 9:44:23 PM A pet owner called to report a canine fatality. He has 4, 3 month old pit bull puppies. Today 1 puppy developed seizures and died at home. The dog owner called a veterinarian who allegedly told him that not much could be done to treat the puppy although the dog was not examined by the veterinarian. Another puppy is now lethargic and the remaining two are asymptomatic. The caller reports that he saw green material in the feces of the puppy that died. His neighbor has Tomcat Rat & Mouse Bait pellets out under his bird feeder and the caller thinks the puppies may have ingested this product yesterday or this morning. He states that it is possible that there is more than one type of rodenticide on his neighbors property and may also be an unspecified snake poison under the bird feeder too. Immediate veterinary intervention was recommended.


To be determined by Registrant

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

Minor

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

Pit Bull Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.3

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Seizure

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 Potential ingestion of this or other pesticides

17. Provide any additional details about the incident

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

12/21/2016 9:44:23 PM A pet owner called to report a canine fatality. He has 4, 3 month old pit bull puppies. Today 1 puppy developed seizures and died at home. The dog owner called a veterinarian who allegedly told him that not much could be done to treat the puppy although the dog was not examined by the veterinarian. Another puppy is now lethargic and the remaining two are asymptomatic. The caller reports that he saw green material in the feces of the puppy that died. His neighbor has Tomcat Rat & Mouse Bait pellets out under his bird feeder and the caller thinks the puppies may have ingested this product yesterday or this morning. He states that it is possible that there is more than one type of rodenticide on his neighbors property and may also be an unspecified snake poison under the bird feeder too. Immediate veterinary intervention was recommended.


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.