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Consumer Product Safety

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

  • Respiratory System
    • Symptom - Dyspnea
  • Skin
    • Symptom - Pale mucous membrane colour
  • General
    • Symptom - Death

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