Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0192

2. Registrant Information.

Registrant Reference Number: 3163844

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.

06-JAN-22

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

27-DEC-20

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?

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?

Yes

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: Male

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Other
  • Specify - Cardiac Arrest

• General
  • Symptom - Other
  • Specify - heart failure

• Respiratory System
  • Symptom - Coughing
  • Specify - Coughing up unknown substance

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

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

Other

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>1 mo <=2 mos / > 1 mois < = 2 mois

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.)

1/6/2022 Caller had a renter in a trailer that was using the product and not using a bait box. The trailer was infested with rats, and there was feces everywhere. Caller had to renovate the trailer, and removed ceilings and floor to repair damage. Caller never came in contact with the product, and he is worried that it was laying around in the area where he was working. About 2 months into renovating the trailer, on 12/27/2020, he went into cardiac arrest. Caller was also coughing up an unknown substance that day. He was hospitalized and diagnosed with heart failure. He had a pacemaker and defibrillator placed at that time. The length of the hospital stay is not reported. He has had no issues since, and does remain on a couple of medications for his condition. He did speak with his doctor regarding the product, but his doctor did not provide any input at that time.

To be determined by Registrant

14. Severity classification.

Major

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.