Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-5307
2. Registrant Information.
Registrant Reference Number: 090130385
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.
22-NOV-09
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
18-NOV-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. 270-341
Product Name: Adams Flea and Tick Shampoo
- Active Ingredient(s)
- 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).
Between November 18, 2009 and November 22, 2009 the owner bathed the dog three times with the product to treat fleas.
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
Weimaraner
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
14
7. Weight (provide a range if necessary )
54
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Inappropriate defecation
- Respiratory System
- Symptom - Shortness of breath
- Specify - Shallow Breathing
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 18, 2009, one month before using the product, the owner noticed the dog started acting lethargic. The owner stated that each time after being bathed the lethargy seemed worse. On November 18, 2009 shortly after the bath, the dog became more lethargic. On November 22, 2009 the dog had an episode of inappropriate defecation and shallow breathing after the bath. Later that day, the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended the owner take the dog to the veterinarian and have the veterinarian call for information.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
On December 4, 2009 the owner returned our call to follow up the case. The owner stated that he had not taken the dog to the veterinarian as the dog died on November 23, 2009. The APSS assistant recommended a necropsy, which was refused by the owner, as the body was not available.