Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2899
2. Registrant Information.
Registrant Reference Number: 170084245
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.
22-MAY-17
5. Location of incident.
Country: UNITED STATES
Prov / State: TENNESSEE
6. Date incident was first observed.
20-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 17, 2017 or May 18, 2017 the owner bathed the cat with this product to treat a condition.
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 Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.58
7. Weight (provide a range if necessary )
6.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Inappropriate defecation
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
On May 20, 2017 the cat developed anorexia and adipsia. On May 22, 2017 the owner found the cat dead with feces and vomit around him. The owner then contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that gastrointestinal (GI) upset can be seen if ingested.
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 not considered to be related to causing the clinical situation. The owner declined a consult with an APSS veterinarian and declined a necropsy.