Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0395

2. Registrant Information.

Registrant Reference Number: 2478702

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.

11-JUL-19

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

11-JUL-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. 22239      PMRA Submission No.       EPA Registration No.

Product Name: Contrac Blox Kills Rats & Mice (Canadian)

• Active Ingredient(s)
  • BROMADIOLONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à 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 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

• Gastrointestinal System
  • Symptom - Burning mouth
  • Specify - Burning tongue
  • Symptom - Diarrhea
  • Symptom - Burning throat

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

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.)

On 11-Jul-2019 a consumer reported a piece from a block of bait contacted the skin of her bare food approximately three hours prior to the call. She immediately wiped her foot with a tissue and applied an unspecified essential oil. The consumer then went to work and mistakenly used that same tissue to open her lunch pail. She was asymptomatic but concerned about potential signs. Approximately 1.5 hours later the consumer reported her husband told her the product had been present in their bathroom for quite some time (unspecified how long). She was concerned about possible inhalational exposure due to the steam the shower creates. She reported developing a burning sensation on her tongue and in her throat shortly after her exposure to the product that morning. She also reported that feeling occurred at times due to her fibromyalgia and when she becomes nervous. On 14-Jul-2019 the consumer reported she developed diarrhea on 13-Jul-2019, possibly due to eating bad food. She was also concerned that rodents could have brought crumbs of product onto her table and thus in contact with her food. No further information was received in this case.

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.