Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2559
2. Registrant Information.
Registrant Reference Number: 170071370
Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.
Address: 301 W. Osborn Road
City: Phoenix
Prov / State: Arizona
Country: USA
Postal Code: 85013
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
02-MAY-17
5. Location of incident.
Country: UNITED STATES
Prov / State: MISSOURI
6. Date incident was first observed.
02-MAY-17
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. 270-324
Product Name: Adams Flea and Tick Cleansing Shampoo for Cats and Kittens
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- Guarantee/concentration .75 %
- PYRETHRINS
- Guarantee/concentration .075 %
- PYRIPROXYFEN
- Guarantee/concentration .086 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
On May 2, 2017 the owner bathed the kitten with this product to treat a flea infestation.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Mediumhair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.27
7. Weight (provide a range if necessary )
3.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- General
- Symptom - Weakness
- Symptom - Death
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?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Within minutes of bathing on May 2, 2017 the kitten became weak and then died. Later that day, the owner contacted the Animal Product Safety Service to report the death. The APSS veterinarian stated that the concern would be for dermal irritation. The APSS veterinarian recommended a necropsy, to have a veterinarian call for information (for shipping instructions and label), and to call back with questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The APSS veterinarian stated that the substance was considered to have an unknown likelihood of causing the clinical situation. On May 3, 2017 an APSS technician called to inquire about a necropsy, which the owner declined.