Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-3492

2. Registrant Information.

Registrant Reference Number: 080090907

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.

15-AUG-08

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

13-AUG-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-348

Product Name: Adams Water Based Flea And Tick Mist For Dogs Puppies Cats Kittens

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 2 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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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).

The owner applied the product to her dog on August 11, 2008. On August 13 the dog was very disorientated, foaming at the mouth, and was continually circling. The owner gave the dog milk and the symptoms improved that evening. On Thursday morning, the symptoms returned; the dog passed away that evening.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever Mix

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.5

7. Weight (provide a range if necessary )

70.0

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Disorientation

• Gastrointestinal System
  • Symptom - Salivating excessively

• General
  • Symptom - Abnormal behaviour
  • Specify - Circling
  • 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

On August 13, 2008, the pet appeared disoriented, was salivating excessively, and circling. The owner gave his dog milk and confined the pet. The owner believes that the symptoms improved on the evening of August 13, but the following morning the symptoms recurred. The dog died on August 14, 2008. On August 15, 2008, the Animal Product Safety Service (APSS) veterinarian stated that the risk for exposure to this product is dermal irritation or a crawling sensation on the skin. The APSS veterinarian would not expect severe CNS signs from the exposure. The APSS veterinarian recommended a necropsy and a rabies test, but the owner declined.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

The APSS veterinarian stated that this substance was not related to the clinical situation. A follow was not deemed necessary, since no additional information was expected.