Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2016-4962

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 1847318

Nom du titulaire (nom légal complet, aucune abbréviation): Bell Laboratories, Inc.

Adresse: 3699 Kinsman Blvd

Ville: Madison

État: WI

Pays: USA

Code postal /Zip: 53704

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

19-JUN-16

5. Lieu de l'incident.

Pays: UNITED STATES

État: TEXAS

6. Date de la première observation de l'incident.

18-JUN-16

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 12455-123-3240

Nom du produit: Tomcat Mouse Killer II (pre-loaded resistant bait station)

• Matière active
  • BROMETHALIN
    • Garantie/concentration .01 %

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7. b) Type de formulation.

Appât

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Non

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

1

7. Poids (fournir un ordre de grandeur si nécessaire)

8.00

lbs

8. Voie(s) d'exposition:

Orale

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

• Système gastro-intestinal
  • Symptôme - Vomit

• General
  • Symptôme - Mort
  • Symptôme - Vocalisation

• Systèmes nerveux et musculaire
  • Symptôme - Autre
  • Specify - Running around abnormally
  • Symptôme - Réveil difficile
  • Specify - Down animal, unable to rise

• Système gastro-intestinal
  • Symptôme - Incontinence fécale

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Accidental ingestion/Ingestion accident.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

6/19/2016 11:04:16 PM On June 18, 2016 between a local time of 5am to 6am, 5 adults Chihuahuas, 1 Cocker Spaniel, and possibly four 6-week-old Chihuahua puppies were exposed to an unknown number of Tomcat Mouse Killer II bait blocks. It appears that one or multiple dogs chewed through the sealed, unopened bag, and consumed all the bait from the bag. The caller stated yesterday morning (June 18) is when she discovered the exposure and found multiple piles of green stool on the floor and several piles of vomit. The caller stated Chihuahua 1, whom she expects ingested the largest amount of bait, began crying, running around, laid down, had vomiting episodes, and was defecating on herself until she eventually passed away on her own. The caller stated that Chihuahua 2, was not having any gastrointestinal signs but was unable to move his back legs and also passed away on his own. Chihuahua 3 became lethargic, was unable to use her hind legs, and had tremors. The caller stated she shot and killed this dog so that the pet would not suffer. The caller also stated she had a Cocker Spaniel who is suspected to have run away. The caller believes the pet likely ingested some of the rodent bait, but did not note any symptoms prior to the pet's disappearance. The caller has another Chihuahua, who has recently began having a vacant look to her eyes and seems weak. The caller also has a litters of 6 week old Chihuahua puppies, all which have distended abdomens and watery, vacant eyes. The caller has not noted any green bait in the stool of the puppies. The caller did not have the packaging from the chewed apart bag so an EPA number could not be obtained, but stated it contained the Tomcat Mouse Killer II. The caller does have a pre-loaded bait station, but that was not touched by the dogs. It was discussed with the caller that this product contains the Bromethalin and this bait works by causing swelling within the brain and when toxic doses are ingested we are likely to see signs between 2 to 24 hours following ingestion such as lethargy, ataxia, tremors, and seizures. Discussed that based on the size of her adult Chihuahuas each pet would only need to ingest about 1.5 tsp before a toxic dose has been consumed. Emergency medical evaluation for all remaining pets in the household was strongly recommended but declined by the pet owner who stated she would just monitor her pets at home.

---

À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

1

5. Sexe:

Homme

6. Âge (fournir un ordre de grandeur si nécessaire)

3

7. Poids (fournir un ordre de grandeur si nécessaire)

8.00

lbs

8. Voie(s) d'exposition:

Orale

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Mort

• Systèmes nerveux et musculaire
  • Symptôme - Paralysie

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Accidental ingestion/Ingestion accident.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

6/19/2016 11:04:16 PM On June 18, 2016 between a local time of 5am to 6am, 5 adults Chihuahuas, 1 Cocker Spaniel, and possibly four 6-week-old Chihuahua puppies were exposed to an unknown number of Tomcat Mouse Killer II bait blocks. It appears that one or multiple dogs chewed through the sealed, unopened bag, and consumed all the bait from the bag. The caller stated yesterday morning (June 18) is when she discovered the exposure and found multiple piles of green stool on the floor and several piles of vomit. The caller stated Chihuahua 1, whom she expects ingested the largest amount of bait, began crying, running around, laid down, had vomiting episodes, and was defecating on herself until she eventually passed away on her own. The caller stated that Chihuahua 2, was not having any gastrointestinal signs but was unable to move his back legs and also passed away on his own. Chihuahua 3 became lethargic, was unable to use her hind legs, and had tremors. The caller stated she shot and killed this dog so that the pet would not suffer. The caller also stated she had a Cocker Spaniel who is suspected to have run away. The caller believes the pet likely ingested some of the rodent bait, but did not note any symptoms prior to the pet's disappearance. The caller has another Chihuahua, who has recently began having a vacant look to her eyes and seems weak. The caller also has a litter of 4, 6 week old Chihuahua puppies, all which have distended abdomens and watery, vacant eyes. The caller has not noted any green bait in the stool of the puppies. The caller did not have the packaging from the chewed apart bag so an EPA number could not be obtained, but stated it contained the Tomcat Mouse Killer II. The caller does have a pre-loaded bait station, but that was not touched by the dogs. It was discussed with the caller that this product contains bromethalin and this bait works by causing swelling within the brain and when toxic doses are ingested we are likely to see signs between 2 to 24 hours following ingestion such as lethargy, ataxia, tremors, and seizures. Discussed that based on the size of her adult Chihuahuas each pet would only need to ingest about 1.5 tsp before a toxic dose has been consumed. Emergency medical evaluation for all remaining pets in the household was strongly recommended but declined by the pet owner who stated she would just monitor her pets at home.

---

À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

1

7. Poids (fournir un ordre de grandeur si nécessaire)

8.00

lbs

8. Voie(s) d'exposition:

Orale

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Lethargie

• Systèmes nerveux et musculaire
  • Symptôme - Tremblements musculaires
  • Symptôme - Paralysie
  • Specify - unable to use back legs

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Euthanised / Euthanasie

16. De quelle manière l'animal a-t-il été exposé?

Accidental ingestion/Ingestion accident.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

6/19/2016 11:04:16 PM On June 18, 2016 between a local time of 5am to 6am, 5 adults Chihuahuas, 1 Cocker Spaniel, and possibly four 6-week-old Chihuahua puppies were exposed to an unknown number of Tomcat Mouse Killer II bait blocks. It appears that one or multiple dogs chewed through the sealed, unopened bag, and consumed all the bait from the bag. The caller stated yesterday morning (June 18) is when she discovered the exposure and found multiple piles of green stool on the floor and several piles of vomit. The caller stated Chihuahua 1, whom she expects ingested the largest amount of bait, began crying, running around, laid down, had vomiting episodes, and was defecating on herself until she eventually passed away on her own. The caller stated that Chihuahua 2, was not having any gastrointestinal signs but was unable to move his back legs and also passed away on his own. Chihuahua 3 became lethargic, was unable to use her hind legs, and had tremors. The caller stated she shot and killed this dog so that the pet would not suffer. The caller also stated she had a Cocker Spaniel who is suspected to have run away. The caller believes the pet likely ingested some of the rodent bait, but did not note any symptoms prior to the pet's disappearance. The caller has another Chihuahua, who has recently began having a vacant look to her eyes and seems weak. The caller also has a litters of 6 week old Chihuahua puppies, all which have distended abdomens and watery, vacant eyes. The caller has not noted any green bait in the stool of the puppies. The caller did not have the packaging from the chewed apart bag so an EPA number could not be obtained, but stated it contained the Tomcat Mouse Killer II. The caller does have a pre-loaded bait station, but that was not touched by the dogs. It was discussed with the caller that this product contains the Bromethalin and this bait works by causing swelling within the brain and when toxic doses are ingested we are likely to see signs between 2 to 24 hours following ingestion such as lethargy, ataxia, tremors, and seizures. Discussed that based on the size of her adult Chihuahuas each pet would only need to ingest about 1.5 tsp before a toxic dose has been consumed. Emergency medical evaluation for all remaining pets in the household was strongly recommended but declined by the pet owner who stated she would just monitor her pets at home.

---

À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

0.7

7. Poids (fournir un ordre de grandeur si nécessaire)

8.00

lbs

8. Voie(s) d'exposition:

Orale

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Faiblesse

• Oeil
  • Symptôme - Autre
  • Specify - Vacant look in the eyes

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Unknown/Inconnu

16. De quelle manière l'animal a-t-il été exposé?

Accidental ingestion/Ingestion accident.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

6/19/2016 11:04:16 PM On June 18, 2016 between a local time of 5am to 6am, 5 adults Chihuahuas, 1 Cocker Spaniel, and possibly four 6-week-old Chihuahua puppies were exposed to an unknown number of Tomcat Mouse Killer II bait blocks. It appears that one or multiple dogs chewed through the sealed, unopened bag, and consumed all the bait from the bag. The caller stated yesterday morning (June 18) is when she discovered the exposure and found multiple piles of green stool on the floor and several piles of vomit. The caller stated Chihuahua 1, whom she expects ingested the largest amount of bait, began crying, running around, laid down, had vomiting episodes, and was defecating on herself until she eventually passed away on her own. The caller stated that Chihuahua 2, was not having any gastrointestinal signs but was unable to move his back legs and also passed away on his own. Chihuahua 3 became lethargic, was unable to use her hind legs, and had tremors. The caller stated she shot and killed this dog so that the pet would not suffer. The caller also stated she had a Cocker Spaniel who is suspected to have run away. The caller believes the pet likely ingested some of the rodent bait, but did not note any symptoms prior to the pet's disappearance. The caller has another Chihuahua (subform 4), who has recently began having a vacant look to her eyes and seems weak. The caller also has a litters of 6 week old Chihuahua puppies, all which have distended abdomens and watery, vacant eyes. The caller has not noted any green bait in the stool of the puppies. The caller did not have the packaging from the chewed apart bag so an EPA number could not be obtained, but stated it contained the Tomcat Mouse Killer II. The caller does have a pre-loaded bait station, but that was not touched by the dogs. It was discussed with the caller that this product contains the Bromethalin and this bait works by causing swelling within the brain and when toxic doses are ingested we are likely to see signs between 2 to 24 hours following ingestion such as lethargy, ataxia, tremors, and seizures. Discussed that based on the size of her adult Chihuahuas each pet would only need to ingest about 1.5 tsp before a toxic dose has been consumed. Emergency medical evaluation for all remaining pets in the household was strongly recommended but declined by the pet owner who stated she would just monitor her pets at home.

---

À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Modérée

19. Donner des renseignements additionnels ici

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.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

4

5. Sexe:

Inconnu

6. Âge (fournir un ordre de grandeur si nécessaire)

0.02

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

• Système gastro-intestinal
  • Symptôme - Distension abdominale

• Oeil
  • Symptôme - Épiphora
  • Symptôme - Autre
  • Specify - Vacant look in the eyes

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Unknown/Inconnu

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser No known exposure.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

6/19/2016 11:04:16 PM On June 18, 2016 between a local time of 5am to 6am, 5 adults Chihuahuas, 1 Cocker Spaniel, and possibly four 6-week-old Chihuahua puppies were exposed to an unknown number of Tomcat Mouse Killer II bait blocks. It appears that one or multiple dogs chewed through the sealed, unopened bag, and consumed all the bait from the bag. The caller stated yesterday morning (June 18) is when she discovered the exposure and found multiple piles of green stool on the floor and several piles of vomit. The caller stated Chihuahua 1, whom she expects ingested the largest amount of bait, began crying, running around, laid down, had vomiting episodes, and was defecating on herself until she eventually passed away on her own. The caller stated that Chihuahua 2, was not having any gastrointestinal signs but was unable to move his back legs and also passed away on his own. Chihuahua 3 became lethargic, was unable to use her hind legs, and had tremors. The caller stated she shot and killed this dog so that the pet would not suffer. The caller also stated she had a Cocker Spaniel who is suspected to have run away. The caller believes the pet likely ingested some of the rodent bait, but did not note any symptoms prior to the pet's disappearance. The caller has another Chihuahua, who has recently began having a vacant look to her eyes and seems weak. The caller also has a litters of 6 week old Chihuahua puppies, all which have distended abdomens and watery, vacant eyes. The caller has not noted any green bait in the stool of the puppies. The caller did not have the packaging from the chewed apart bag so an EPA number could not be obtained, but stated it contained the Tomcat Mouse Killer II. The caller does have a pre-loaded bait station, but that was not touched by the dogs. It was discussed with the caller that this product contains the Bromethalin and this bait works by causing swelling within the brain and when toxic doses are ingested we are likely to see signs between 2 to 24 hours following ingestion such as lethargy, ataxia, tremors, and seizures. Discussed that based on the size of her adult Chihuahuas each pet would only need to ingest about 1.5 tsp before a toxic dose has been consumed. Emergency medical evaluation for all remaining pets in the household was strongly recommended but declined by the pet owner who stated she would just monitor her pets at home.

---

À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mineure

19. Donner des renseignements additionnels ici

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.