Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-1364

2. Registrant Information.

Registrant Reference Number: 2023-US-001673

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

Address: 711 E. Missouri Avenue, Suite 200

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.

23-JAN-23

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

6. Date incident was first observed.

23-JAN-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)

---

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 %

---

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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Pit Bull

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

70

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Eye
  • Symptom - Decreased vision

• General
  • Symptom - Vocalizing
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Disorientation
  • Specify - Bumping into walls

12. How long did the symptoms last?

Persisted until death

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

Unknown

14. a) Was the animal hospitalized?

Unknown

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 23 Jan 2023 the animal owner's family member bathed the dog with the product. Immediately following exposure, the dog developed vocalization (whining) and decreased vision, the dog was bumping into walls due to the vision impairment. Animal owner was uncertain if there were any other flea and tick products used on the pet. Veterinary care was sought, but results of examination and if treatments were performed is unknown. Within 48 hours following following exposure, the dog died. Date, time, and method of death are unknown. No further information is expected.

---

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. Ocular irritation may occur if there is ocular exposure. However, impaired or decreased vision would not be expected. Vocalization may be secondary to stress from decreased vision or other causes. Death is not expected. Other causes for the clinical signs including trauma from bathing, use of other products, and underlying disease remain in strong consideration. Results of veterinary examination and diagnostics including necropsy may have been able to provide further information about the cause of death, but these were not reported or may not have been performed. 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.