Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5804
2. Registrant Information.
Registrant Reference Number: 070062902
Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.
Address: 301 West Osborn Road
City: Phoenix
Prov / State: AZ
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.
20-JUN-07
5. Location of incident.
Country: UNITED STATES
Prov / State: TENNESSEE
6. Date incident was first observed.
20-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.
2
Other Units: tbsp
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).
The owner applied 2 tablespoons of the product to her 9 year old Persian, neutered, female cat weighing 6 pounds on June 20, 2007 at 4:30 PM CDT.
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
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Persian
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
6
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 - Lethargy
- Symptom - Death
12. How long did the symptoms last?
<=30 min / <=30 min
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 20, 2007 at 4:30 PM CDT, the owner bathed her cat with the product. Owner stated to the Animal Product Safety Staff (APSS) that when the cat was in the water, the water turned red (presumably due to a heavy flea infestation.) The cat was severely lethargic fifteen minutes after the bath. At 5:00 PM CDT on June 20, 2007, the cat died. The APSS staff member advised the owner to take the animal to the veterinarian, and have the attending veterinarian contact the APSS facility for treatment recommendations.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Persian
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
6
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
- Nervous and Muscular Systems
12. How long did the symptoms last?
Unknown / Inconnu
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
Fully Recovered / Complètement 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 20, 2007, the owner bathed her cat with the product. Owner stated to the Animal Product Safety Staff (APSS) that when the cat was in the water, the water turned red (presumably due to a heavy flea infestation). Cat was shivering, but acting normal.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here