Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-3858

2. Registrant Information.

Registrant Reference Number: 1-19267503

Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.

Address: 301 West Osborn Road

City: Phoenix

Prov / State: Arizona

Country: USA

Postal Code: 85013

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

23-JUL-09

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

16-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. 270-300

Product Name: Equicare Flysect Super-7 Repellent Spray

• Active Ingredient(s)
  • BUTOXYPOLYPROPYLENE GLYCOL
    • Guarantee/concentration 5 %
  • DI-N-PROPYL ISOCINCHOMERONATE
    • Guarantee/concentration 1 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 2 %
  • PERMETHRIN
    • Guarantee/concentration .2 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Tingling skin

• General
  • Symptom - Swelling

• Cardiovascular System
  • Symptom - Fainting

• Gastrointestinal System
  • Symptom - Vomiting

• Cardiovascular System
  • Symptom - Hypotension

• Nervous and Muscular Systems
  • Symptom - Unconsciousness

• Skin
  • Symptom - Paresthesia

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

On July 16, 2009 patient got less than 1 teaspoon of product on her hand while transferring a refill bottle of product into a spray bottle. She rinsed her hand off with a hose and sprayed three horses with the product. She went inside to take a shower afterward. Once in the bathroom, she felt like she had "thousands of bugs under her skin" and started to swell rapidly. She turned on the cold water and scrubbed her hands and feet with soap, but had to jump out of the shower because she knew something was wrong. She ran to the bedroom and called 911. She told them that she was having an allergic reaction. While waiting for the ambulance she passed out in the hall. When she woke, she was vomiting and vomiting. She continued to vomit in the ambulance.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The patient was kept in the hospital until 2:30 AM. Caller notes that she was given an Epi-Pen in the ambulance. Her blood pressure dropped from "120/something to 50/10". She was given IV steroids. Upon discharge, she was instructed to take Zantac twice daily and Benadryl three times per day. Caller states she is normally an active, healthy woman.