Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-3155

2. Registrant Information.

Registrant Reference Number: 3699249

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.

25-AUG-23

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

23-AUG-23

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. Unknown

Product Name: Bromethalin (non-specific)

• Active Ingredient(s)
  • BROMETHALIN
    • 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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

75.00

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

• Blood
  • Symptom - Bleeding

• General
  • Symptom - Death

• Skin
  • Symptom - Bruises

• Gastrointestinal System
  • Symptom - Oral hemorrhage
  • Symptom - Other
  • Specify - Yellow foam in his stool

• General
  • Symptom - Abnormal behaviour

• Respiratory System
  • Symptom - Nose bleed

12. How long did the symptoms last?

Persisted until death

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Although ingestion is suspected, no exposure was witnessed to the product.

17. Provide any additional details about the incident

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

8/25/2023 Caller states that her neighbor laid out a suspected Bromethalin Tomcat bait in their yard starting on 22Aug2023. Her dogs have free access to this yard at all times but had no witnessed ingestion of the product. Caller states she did not see any signs or symptoms in [Name] until approximately 23Aug2023 when he was noted to have bleeding at his gumline. Caller states on 24Aug2023 he had some yellow foam in his stool in the morning and at night was not wanting to go upstairs to sleep in his routine bedtime area. Caller states the morning of 25Aug2023 they found him deceased; he was taken to a veterinarian who confirmed he was deceased and determined he had bleeding from his nose and bruising on his chest and genitals. Veterinarian mentioned this could be from a rodenticide and encouraged animal owner to investigate if her dogs had access to any rodenticide. Caller then met with her neighbor who showed her the Tomcat she had put in her yard and animal owner is fairly certain the active ingredient is Bromethalin; that being said the animal owner cannot verify any product information outside of name and suspected active ingredient. Caller was primarily concerned with her dog that is still living, [Name], who was known to ingest the feces of [Name]. Caller states she saw no signs of green pigment in [Name]'s stool because [Name] would often eat it. Caller states [Name] is asymptomatic but she is concerned that he could have a relay toxicity or a potential underlying exposure that has yet to manifest. Caller would like to know if we would anticipate toxicity considering case details and if there was any form of treatment that could be provided if [Name] shows signs or symptoms of toxicity. No further information is available.

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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.