Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5923
2. Registrant Information.
Registrant Reference Number: 070085147
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.
11-AUG-07
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
11-AUG-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. 270341
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?
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Miniature Poodle
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
0.11
7. Weight (provide a range if necessary )
5
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
- Skin
- Symptom - Pale mucous membrane colour
12. How long did the symptoms last?
<=30 min / <=30 min
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
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 August 11, 2007 at 2:00 PM, +/- 2 hours, CDT, the owner was going to bathe the dog with the shampoo but noticed that the dog was too young. The owner had some of the product on his hands and washed them off in the sink, and then the dog licked some of the water out of the sink. At 4:00 PM CDT, on the same day, the dog began to experience dyspnea and had pale mucous membrane color. On August 11, 2007 at 4:06 PM CDT, the APSS staff recommended the owner take the dog to the veterinarian, for the attending veterinarian to give a diagnostic evaluation and to call the APSS facility back for information. On August 11, 2007 at 4:20 PM CDT, the dog died while at the regular veterinarian. The APSS staff recommended that a necropsy be performed, but the owner refused.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here