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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2009-4806

2. Registrant Information.

Registrant Reference Number: 090123058

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.


5. Location of incident.



6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-307

Product Name: Adams Plus Flea and Tick Mist with Insect Growth Regulator

  • Active Ingredient(s)
      • Guarantee/concentration 1 %
      • Guarantee/concentration .18 %
      • Guarantee/concentration .125 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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 31, 2009 the owner lightly sprayed the product on the dog to treat fleas.

To be determined by Registrant

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


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire Terrier

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


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


  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Hiding
  • Nervous and Muscular Systems
    • Symptom - Trembling
  • General
    • Symptom - Lethargy
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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 November 1, 2009 the owner noticed the dog was anorexic, hiding, and trembling. She bathed the dog four times with baby shampoo that day. On November 3, the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended the owner take the dog to the veterinarian, have the veterinarian call for information, and call back with questions. On November 4, 2009 the regular veterinarian called and spoke with an APSS veterinarian regarding the supportive care the dog was receiving. The regular veterinarian indicated that the dog does have "horrendous teeth" which could account for the anorexia. She also thinks dog might be a bit neurologic in the hind legs , but owner says dog has always been that way. On November 9, 2009 the owner called APSS to report that the dog was found dead. She also mentioned that the dog had been severely lethargic on November 8, 2009. The APSS veterinarian recommended the owner take the dog to the regular veterinarian and have the veterinarian call for necropsy information. On November 9, 2009 the veterinary clinic staff contacted APSS to discuss the necropsy.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here

Necropsy results are pending.