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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0506

2. Registrant Information.

Registrant Reference Number: 2159653

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.

20-DEC-17

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

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)

  • Active Ingredient(s)
    • BROMETHALIN
      • Guarantee/concentration .01 %

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

28

Units: g

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

Site: Res. - In Home / Rs. - 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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

50.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Blood
    • Symptom - Bleeding
  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Vomiting
  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Weight loss
    • Symptom - Other
    • Specify - Stomach abnormality

12. How long did the symptoms last?

Persisted until death

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

Yes

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 exposure to pesticide

17. Provide any additional details about the incident

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

12/20/2017 2:00:02 PM A pet owner reported that she had one 28 gram block of Tomcat Mouse Killer I in a bait station in her garage. Her pets did not have access to that area, but she was concerned about possible ingestion of the bait or exposed rodents by her dog. No ingestion was witnessed. On December 1, 2017 the owner noted the dog was anorexic for the previous 3 days and had vomited twice that morning. The dog was taken to a veterinarian and found to weigh 9 pounds less than it had previously. The veterinarian performed surgery on the dog and noted something wrong with the stomach (caller could not specify further) and that the dogs internal organs were bleeding when touched. The dog was prescribed an oral steroid and an antibiotic and discharged. On December 4, 2017 the dog was taken back to the veterinarian as signs were not improving. The dog was then prescribed vitamin K1 and a digestive support supplement. The dog died at home during the night on December 6, 2017.


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.