Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2462
2. Registrant Information.
Registrant Reference Number: 1984038
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
Environment
4. Date registrant was first informed of the incident.
30-JAN-17
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
Unknown
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. 12455-120-3240
Product Name: Tomcat Mouse Killer I (refillable resistant bait station)
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Unknown
9. Application Rate.
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).
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
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
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
- Nervous and Muscular Systems
- Symptom - Coma
- Symptom - Seizure
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?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Speculated ingestion of bait.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1/30/2017 11:55:19 AM A dog owner reported that he believes one of his dogs died from bromethalin rodenticide poisoning. The caller was a very poor historian and difficult to keep on track or obtain detail from. We were unable to determine when the dogs death took place although he mentioned that the dog was seen by three different veterinarians, one of whom noted that the dog had an elevated white blood cell count. At an unknown point in time, the dog developed a coma and/or seizures. We were not able to obtain the name, breed, age, or weight of this dog. The caller also mentioned that he had found dead owls in his local area which he also attributed to bromethalin since his neighbor uses bromethalin baits.
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 IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Bird - Predatory / Oiseau - De proie
2. Common name(s)
Owl
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
A neighborhood resident reported that he found dead owls in his locale which he suspected scummed to bromethalin poisoning because his neighbor uses bromethalin on his property. The caller was extremely difficult to obtain details from and were were unable to obtain a better understanding of the incident.
8. a) Was the incident a result of (select all that apply)
N/A
Unknown
8. b) i) How many times has the product been applied this year?
8. b) ii) What was the date of the last application?
9. Did it rain
9. a) During application?
No
9. b) Up to 3 days after application?
No
10. a) Was there a buffer zone?
No
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
Major
13. Please provide supplemental information here