Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-4585
2. Registrant Information.
Registrant Reference Number: 090114256
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.
11-OCT-09
5. Location of incident.
Country: UNITED STATES
Prov / State: WISCONSIN
6. Date incident was first observed.
08-OCT-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. 270-343
Product Name: Adams Flea and Tick Mist
- 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 %
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 October 8, 2009 the owner sprayed an unknown amount of the product on the dog.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Shetland Sheepdog
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
40
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
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Anorexia
- Nervous and Muscular Systems
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 October 8, 2009, approximately four hours after being sprayed with product, the dog began vomiting and became lethargic, disoriented, and anorexic. On October 9, 2009 the owner applied K9 Advantix. On October 11, 2009 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that no problems are expected days after application of the product. She also stated that if ingested, self limiting drooling or vomiting can be seen. The APSS technician relayed the APSS veterinarian's recommendations to the owner: bathe the dog with dish soap; call back with questions; and if the dog is not eating, still lethargic and disoriented, take the dog to the veterinarian; and have the veterinarian call for information. In addition, this dog had hip dysplasia and was given canine aspirin BID.
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 doubtful likelihood of causing the clinical situation. On October 16, 2009 the owner called and spoke with an APSS veterinarian to follow up the case. She stated that she thought the dog was improving, so she didn't take her to the vet. The dog then worsened and died quickly on October 13, 2009 at 12 p.m. The body was buried.