Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-6160

2. Registrant Information.

Registrant Reference Number: 2021-US-034651

Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.

Address: 301 W. Osborn Road

City: Phoenix

Prov / State: Arizona

Country: United States of America

Postal Code: 85013

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

22-AUG-21

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

20-AUG-21

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. 270-324

Product Name: Adams Flea and Tick Cleansing Shampoo For Use on Dogs,Cats,Puppies,Kit

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .075 %
  • PYRIPROXYFEN
    • Guarantee/concentration .086 %

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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).

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Pomeranian Spitz

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

4.536

kg

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Rectal hemorrhage
  • Symptom - Vomiting
  • Symptom - Anorexia

• Respiratory System
  • Symptom - Coughing up blood

• Nervous and Muscular Systems
  • Symptom - Seizure

• General
  • Symptom - Death
  • Symptom - Adipsia

• Nervous and Muscular Systems
  • Symptom - Recumbent

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 20 Aug 2021, the dog was bathed with the product by the animal owners. The dog was then placed in an outdoor enclosure where he was swarmed by wasps, unable to get away, and was laying on the ground (coded as lethargy). The animal owners then bathed the dog to remove any potential residue of the product, dried the dog with a hair dryer, and attempted to administer honey. During this time the dog developed rectal bleeding, vomited twice, was anorexic and not drinking, coughed up blood, and developed seizures. Within 4 hours of product use, the dog died. No further information is expected.

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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

Assessment: This product has a wide margin of safety. Mild dermal irritation is possible following topical use. If ingested, mild self-limiting GI irritation may occur. The severity of clinical signs and death are not expected following product use. Swarming and stinging by wasps is also not expected following product use. The subsequent clinical signs displayed are consistent with a reaction to multiple wasp stings. Veterinary examination and diagnostics including necropsy may have been able to provide further information, but these were not pursued. 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 cannot 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.