Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-0532
2. Registrant Information.
Registrant Reference Number: 090010360
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.
27-JAN-09
5. Location of incident.
Country: UNITED STATES
Prov / State: UNKNOWN
6. Date incident was first observed.
27-JAN-09
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. 270-294
Product Name: Bronco Water Base Equine Fly Spray Plus Citronella Scent
- Active Ingredient(s)
- PERMETHRIN
- Guarantee/concentration .1 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .5 %
- PYRETHRINS
- Guarantee/concentration .05 %
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).
On January 27, 2009, the owner applied the substance to the dog to treat for a tick and flea infestation.
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
German Shepherd Dog
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.67
7. Weight (provide a range if necessary )
15
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Bloody diarrhea
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
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 January 27, 2009, the puppy became anorexic, lethargic, and had bloody diarrhea. The owner then bathed the dog with mild shampoo and water.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The owner stated that he took the puppy to the veterinarian on the evening of the call. The puppy died on January 28, 2009. Owner thinks the puppy was poisoned.