Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0924

2. Registrant Information.

Registrant Reference Number: 090021980

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-FEB-09

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

27-FEB-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-343

Product Name: Adams Flea And Tick Mist Insecticide Repellent And Deodorant For Dogs

• Active Ingredient(s)
  • DI-N-PROPYL ISOCINCHOMERONATE
    • Guarantee/concentration .5 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .51 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.5 %
  • PYRETHRINS
    • Guarantee/concentration .15 %

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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).

On February 24, 2009, the owner applied the product to the cat to treat a 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

Cat / Chat

3. Breed

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.38

7. Weight (provide a range if necessary )

6

lbs

8. Route(s) of exposure

Skin

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Drooling

• General
  • Symptom -
  • Specify - Excessive Grooming

• Respiratory System
  • Symptom - Dyspnea

• Renal System
  • Symptom - Urinary incontinence

• General
  • Symptom - Death

12. How long did the symptoms last?

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

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 February 24, 2009, the pet began to hypersalivate and groom himself excessively. On February 27, 2009, the pet was dyspneic and urinated on himself. The owner gave the pet some milk. The Animal Product Safety Service (APSS) was contacted that same day. The APSS veterinarian recommended that the owner take the pet to the veterinarian and have the veterinarian call for information.

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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 the substance was considered to have a low likelihood of causing the clinical situation. On follow up with the pet owner, the APSS technician learned that the pet died on the same day as the consultation with APSS. Veterinary care was not sought.