Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-4386
2. Registrant Information.
Registrant Reference Number: 070056917
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.
06-JUN-07
5. Location of incident.
Country: UNITED STATES
Prov / State: OKLAHOMA
6. Date incident was first observed.
05-JUN-07
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. 374254
Product Name: Adams Flea And Tick Shampoo For Dogs Puppies Cats Kittens
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .5 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration 1.5 %
- PYRETHRINS
- Guarantee/concentration .15 %
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 June 4, 2007 at 11:00 am CDT, the owner bathed his 2 month old, 10 pound, male, intact, Beagle Dog with said product in an attempt to remove the heavy infestation of fleas.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Beagle
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
.16
7. Weight (provide a range if necessary )
10
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- Symptom - Diarrhea
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Not recovered / Non rétabli
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 June 5, 2007 at 7:00 am, CDT, twenty hours after the owner bathed the puppy in said product, the owner noted that the animal was anorexic, vomiting, and having bouts of diarrhea. On June 6, 2007 at 8:29 am, CDT, the owner contacted the APSS facility to report the exposure and the signs his animal was displaying. The APSS staff member stated that she would not expect serious problems and also noted that the signs the puppy was displaying were not likely correlated with the exposure. The APSS staff member recommended the owner take the symptomatic puppy into a referring veterinary clinic; owner declined due to financial restrictions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The owner stated to the APSS staff that he found the puppy as a stray the day the exposure occurred. Per the owner, the dog has never been seen by a vet but intestinal parasites were noted in the feces. The owner contacted the APSS facility on June 7, 2007 at 9:03 am, CDT, to report that the animal had died. The APSS staff member offered to transfer the owner to an APSS DVM but the owner declined.