Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-0498

2. Registrant Information.

Registrant Reference Number: 2241133

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.

Human

4. Date registrant was first informed of the incident.

26-MAY-18

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

26-MAY-18

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. 30757      PMRA Submission No.       EPA Registration No.

Product Name: Tomcat Mouse Killer (disposable bait station) (Canadian)

• Active Ingredient(s)
  • BROMETHALIN

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7. b) Type of formulation.

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Chills

• Respiratory System
  • Symptom - Shortness of breath

• Skin
  • Symptom - Itchy skin
  • Symptom - Tingling skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

5/26/2018 7:39:43 PM A woman reported that she found a bait station in a vent in her home about 30 minutes prior. She had been experiencing itching all over her body, chills, a tingling sensation, and shortness of breath since that morning. She denied touching the bait station or the bait inside it. The bait station was intact. The caller had washed her hands. She noted a room in her home smelled abnormally and wanted to know what signs would be expected if she were poisoned by the product. Given the symptoms reported, the caller was advised to wash for 15 minutes, ventilate the room with the abnormal smell, and to seek fresh air outside. She could also take a dose of an over-the-counter antihistamine. Due to the difficulty breathing since that morning, evaluation at an emergency department was recommended. The caller then abruptly disconnected the call. No further information was received in this case, so the outcome is unknown.

To be determined by Registrant

14. Severity classification.

Minor

15. 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.