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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5810

2. Registrant Information.

Registrant Reference Number: 070074265

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

Address: 301 W. Osborn Rd.

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.


5. Location of incident.



6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270343

Product Name: Adams Flea & Tick Mist Insecticide Repellent & Deodorant

  • Active Ingredient(s)
      • Guarantee/concentration .5 %
      • Guarantee/concentration .51 %
      • Guarantee/concentration 1.5 %
      • Guarantee/concentration .15 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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 26, 2007 at approximately 12:04 p.m. CDT and continuing until July 9, 2007 at 11:48 a.m. CDT, the owner applied the product to her 2 year old, intact, male, miniature Schnauzer on three occasions. The product was applied dermally each time to prevent fleas and ticks, and the use was appropriate.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Miniature Schnauzer

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Bloody vomit
  • Renal System
    • Symptom - Inappropriate urination
    • Specify - inappropriate urination
  • General
    • Symptom - Vocalizing
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • Blood
    • Symptom - Hyperphosphatemia
    • Symptom - Hypoglycemia
    • Symptom - Hyponatremia
  • Eye
    • Symptom - Nystagmus
  • Nervous and Muscular Systems
    • Symptom - Muscle tremors
    • Symptom - Coma
  • General
    • Symptom - Death

12. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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


14. a) Was the animal hospitalized?


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 July 11, 2007 at 8:00 a.m. CDT, the owner noticed that the patient was anorexic. At 1:30 p.m. CDT on July 11, 2007, the patient was having bloody vomitus, was urinating inappropriately, was vocalizing, and was having seizures. The owner took the patient to the regular veterinarian where he was treated symptomatically and supportively. The veterinary staff performed laboratory tests at 2:00 p.m. CDT on July 11, 2007 and found that the patient's serum phosphorus and serum glucose were high, but his sodium levels were low. Also at that time, the patient was showing nystagmus, tremors, and was in a coma. On July 11, 2007 at approximately 5:30 p.m., the veterinary staff referred the owner to the emergency clinic. However, the patient did not arrive there until 9:30 that evening. On July 12, 2007 at 2:00 a.m. CDT, the patient died.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here