Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-0811
2. Registrant Information.
Registrant Reference Number: 1996969
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.
25-FEB-17
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
25-FEB-17
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. 31500
PMRA Submission No.
EPA Registration No.
Product Name: Tomcat Mouse Killer, 28gm blocks
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
7. b) Type of formulation.
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
Pit Bull Terrier
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
60.00
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
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
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
2/25/2017 11:39:53 AM A pet owner reported their dog ingested one block of Tomcat Mouse Killer from inside of a cupboard approximately 10-15 minutes prior to the call. The dog spontaneously vomited and there were some chunks of bait seen in the vomitus, equaling possible one-half of the block. The dog had no prior history of rodenticide exposure. It was recommended that the owner continue to monitor the dog at home for persistence of signs. No other symptoms were reported, and no further information was reported for this case.
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.