Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5812
2. Registrant Information.
Registrant Reference Number: 070075989
Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.
Address: 301 W. 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.
21-JUL-07
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
20-JUL-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. 270255
Product Name: Blue Streak Fly Bait
- Active Ingredient(s)
- (Z)-9-TRICOSENE
- Guarantee/concentration .025 %
- METHOMYL
- Guarantee/concentration 1 %
7. b) Type of formulation.
Granular
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Great Dane
4. Number of animals affected
3
5. Sex
Unknown
6. Age (provide a range if necessary )
0.18
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
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
Not recovered / Non rétabli
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On July 21, 2007 at 11:40 am CDT, the owner's regular DVM called the Animal Product Safety Service (APSS) to discuss the case. According to the regular DVM, the owner placed this product in gallon jugs with holes in it above a run where the puppies were. Three out of five puppies were found dead on July 20, 2007. The owner told the regular DVM that it is possible that during a storm the wind blew some of the product out of the jugs and into the puppy run. The regular DVM performed necropsies on the puppies and found that the intestines were stained the same color as the product, and that the stomach contents looked and smelled like the product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here