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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4227

2. Registrant Information.

Registrant Reference Number: 2444772

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-MAY-19

5. Location of incident.

Country: UNITED STATES

Prov / State: WISCONSIN

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. 12455-132-3240

Product Name: Tomcat with Bromethalin Bait Chunx

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

7. b) Type of formulation.

Bait

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

Bernese Mountain Dog

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

115.00

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

  • Gastrointestinal System
    • Symptom - Loss of appetite
  • General
    • Symptom - Death
    • Symptom - Other
    • Specify - Internal bleeding
    • Symptom - Lethargy
    • Symptom - Weakness
  • Gastrointestinal System
    • Symptom - Weight loss

12. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

5

Day(s) / Jour(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify No known exposure. Speculated ingestion because product was on the same farm as the dog.

17. Provide any additional details about the incident

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

5/20/2019 9:15:48 AM: A farmer and dog owner reported that her dog died 1 month ago, in April of 2019, and she wants to know how much of the bait the dog would have needed to cause toxicity. Loose, unprotected, blocks were placed around the dairy farm on which the dog resides at an unstated point in time before the dog's death. No known exposure occurred. The dog had a litter of puppies in January, 2019 after which she began losing weight. In March or April, 2019, the dog developed a decreased appetite and progressively became weak and lethargic. When the dog was brought to a veterinarian for examination, she was found to have internal bleeding. The dog was hospitalized for 5 days and died. The specific medical tests or treatments performed were not provided. No necropsy was performed.


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.