Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-4227

2. Registrant Information.

Registrant Reference Number: 2020087

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.

11-APR-17

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

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)

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

Product Name: Brodifacoum (non-specific)

• 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. - 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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird / Oiseau

3. Breed

Chicken

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

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 - Death
  • Symptom - Lethargy
  • Symptom - Weakness

• Skin
  • Symptom - Pallor

• Respiratory System
  • Symptom - Laboured breathing
  • Specify - Gasping

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 pesticide.

17. Provide any additional details about the incident

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

4/11/2017 A chicken owner reported that one of her hens died she suspects it ingested the product. Initially, the product was placed in a bait box on the callers property on 4/1/2017 by a pest control operator. The callers husband then moved the bait box close to the fence of the chicken coop a few days following placement. On 4/6/2017, one would not go into the coop at night, which is abnormal. The following day, 4/7/2016, caller notes that the chicken was lethargic, and weak, and had a pale comb. Later that evening the chicken started gasping and then died. On 4/8/17 the caller noticed small red flecks in the hens coop which she thinks were flecks of bait. Medical attention was not sought.

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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.