Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-3151

2. Registrant Information.

Registrant Reference Number: 3919364

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.

24-MAY-24

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

6. Date incident was first observed.

10-MAY-24

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.       PMRA Submission No.       EPA Registration No. 12455-80-3240

Product Name: Tomcat All-Weather Bait Chunx, 4 lb. pail

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Unknown

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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. - Out Home / Rés - à l'ext.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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Blood
  • Symptom - Anemia
  • Symptom - Leukopenia
  • Symptom - Thrombocytopenia

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Nausea
  • Symptom - Vomiting

• Blood
  • Symptom - Hyponatremia

• General
  • Symptom - Other
  • Specify - Transaminitis

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Shakiness

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?

3

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

Application

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)

Chemical resistant gloves

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 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.)

5/24/2024 - The caller reported experiencing nausea, vomiting, diarrhea, and a headache after 3 weeks of cutting up pieces of Tomcat All-Weather Bait Chunx, to use in the ground, and would like to know if these symptoms are associated with a potential dermal exposure to the product. He reports no other exposure. The caller began using this product 3 weeks prior to symptoms. He would cut up pieces of the bait and place them in the ground outdoors. Every time he would touch the product, he would wear gloves. When handling the product, he was outdoors, and not in an enclosed space. He advised that the gloves on one occasion had gotten wet and questioned if the product could have been absorbed through the gloves, then absorbed through the skin. He denies cuts or abrasions on his skin when handling the product. His skin was intact and was still wearing gloves. On 5/10/24, he began experiencing a headache, followed by nausea, vomiting and diarrhea. He denies treatments for the symptoms while at home. He was evaluated at an Urgent Care on 5/15/24 for the symptoms and was advised that he had some tick bites and was prescribed doxycycline. Since symptoms did not improve, he decided to be evaluated at the emergency room the next day. He did not inform urgent care, nor did he inform the emergency room physician about the product since he had not made a connection of what could have caused his symptoms until today. At the emergency room, he had unspecified labs drawn and was diagnosed with acute hyponatremia, thrombocytopenia, leukopenia, mild amenia, and transaminitis. He was hospitalized and released 3 days later. He stated that his prior symptoms resolved but is shaking today. 5/31/2024 - Attempted call back and left message with reason for call, case number and call back number. 6/1/2024 - Consumer called back to follow up about his experience. He stated initially he thought the product was a concern but stated through the discussion with the SCI medical line and his doctor, it's highly unlikely the product was the cause of his symptoms. He indicated he believes it was due to eating an outdated mushroom. He is still following up with his doctor regularly regarding the symptoms and he has an upcoming appointment on 6/10/2024. He reports his symptoms are progressively getting better and are resolving at this time. No further information is available.

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.