Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2781

2. Registrant Information.

Registrant Reference Number: 090083519

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.

25-JUL-09

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

24-JUL-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. 270-279

Product Name: Farnam Equi Spot Spot On Fly Control for Horses

• Active Ingredient(s)
  • OIL OF CITRONELLA
    • Guarantee/concentration 33.2 %
  • PERMETHRIN
    • Guarantee/concentration 45 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

10

Units: mL

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 July 21, 2009 the horse owner applied the product to the horse to control flies.

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

Horse / Cheval

3. Breed

Thoroughbred

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

1400

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

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

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Other
  • Specify - Colic

• General
  • Symptom - Edema

• Renal System
  • Symptom - Other
  • Specify - Urinary Obstruction

• Skin
  • Symptom - Dermatitis

• General
  • Symptom - Death

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 July 24, 2009 the horse had colic, pitting edema, a urinary obstruction, and dermatitis. On July 25, 2009 the horse was seen by the veterinarian and the veterinarian gave the horse fluids, flunixin, and a corticosteroid. Later that same day, the pet owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended that the pet owner have her veterinarian call for information and asked that she call back with questions.

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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

On August 1, 2009, an APSS assistant spoke to the horse owner. The pet owner stated that the horse died on July 26, 2009.