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Consumer Product Safety

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