Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0394

2. Registrant Information.

Registrant Reference Number: 2444864

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: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

17-MAY-19

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. 26859      PMRA Submission No.       EPA Registration No.

Product Name: Jaguar 50 Rodenticide Place Pac Kills Rats & Mice (Canadian)

• Active Ingredient(s)
  • BRODIFACOUM

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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

Border Collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

82.00

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 - Anorexia
  • Symptom - Diarrhea
  • Symptom - Salivating excessively

• General
  • Symptom - Adipsia

• Nervous and Muscular Systems
  • Symptom - Depression
  • Symptom - Ataxia
  • Symptom - Muscle tremors
  • Symptom - Recumbent
  • Specify - Down animal, unable to rise

12. How long did the symptoms last?

Unknown / Inconnu

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?

Unknown

15. Outcome of the incident

Unknown/Inconnu

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

On 20-May-2019 a pet owner reported their dog had been hospitalized since 17-May-2019. On 17-May-2019 the dog developed ataxia, muscle tremors, diarrhea, and excessive salivation. The dog was immediately brought to an emergency veterinarian where blood work, including testing for Lyme disease and blood clotting issues, was performed and found to be normal. The dog was treated with IV fluids, an unspecified muscle relaxant, and an unknown antibiotic. The veterinarian told the owner the dog's signs may be related to ingestion of mold since the dog lives on a farm. Packs of product were recently placed out in the farm lunchroom, but no ingestion of bait by the dog was witnessed. On 20-May-2019 the dog was very depressed, unable to stand, and not eating or drinking (adipsic) while in the hospital. The veterinarian reported that the dog was still exhibiting neurological signs and had no signs of bleeding. The veterinarian confirmed that a PT test (to measure blood clotting ability) performed on 17-May-2019 was normal. On 21-May-2019 the pet owner reported the dog's signs continued. No further information was received so the final case outcome is unknown.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Moderate

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.