Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2551
2. Registrant Information.
Registrant Reference Number: 080062822
Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.
Address: 301 W. Osborn Road
City: Phoenix
Prov / State: Arizona
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-JUN-08
5. Location of incident.
Country: UNITED STATES
Prov / State: ALABAMA
6. Date incident was first observed.
11-JUN-08
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. 270-218
Product Name: Flys Off Insect Repellent For Dogs
- Active Ingredient(s)
- BUTOXYPOLYPROPYLENE GLYCOL
- Guarantee/concentration 17.589 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .375 %
- PYRETHRINS
- Guarantee/concentration .136 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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).
A child sprayed the puppies. The exposure date is unknown.
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Staffordshire Bull Terrier
4. Number of animals affected
2
5. Sex
Male
6. Age (provide a range if necessary )
0.06
7. Weight (provide a range if necessary )
5
lbs
8. Route(s) of exposure
Skin
Oral
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Respiratory System
- Symptom - Dyspnea
- Symptom - Cyanosis
- Skin
- Symptom -
- Specify - Petechiae
- General
- Symptom - Hypothermia
- Symptom - Parasitism
- Specify - Parasitism
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
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
Died
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
Owner stated a small child sprayed 5 puppies with the product. One developed symptoms and was euthanized, the other died suddenly.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here