Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-6190
2. Registrant Information.
Registrant Reference Number: 070087749
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.
17-AUG-07
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
17-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. 270278
Product Name: Adams Flea and Tick Control for Dogs Under 15 lbs
- Active Ingredient(s)
- PERMETHRIN
- Guarantee/concentration 45 %
- PYRIPROXYFEN
- Guarantee/concentration 5 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Units: mL
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 August 17,2007 at 12:00 PM CDT, the owner applied the product to her cat.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
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 17, 2007 at 5:00 PM CDT, the owner noticed that the cat was experiencing tremors. The owner bathed the cat at 6:00 PM CDT. At 6:12 PM CDT, on the same day, the APSS staff stated that this situation was treatable, but would require a veterinarian as soon as possible. The APSS staff recommended that the owner take the cat to the veterinarian. The APSS staff also recommended that the attending veterinarian administer methocarbamol and call the APSS facility back for information if needed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here