Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-0585
2. Registrant Information.
Registrant Reference Number: 0100005670
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.
16-JAN-10
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
14-JAN-10
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. 270-373
Product Name: Just One Bite II Bait Chunk
- Active Ingredient(s)
- BROMADIOLONE
- Guarantee/concentration .005 %
7. b) Type of formulation.
Bait
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Siberian Husky
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
13
7. Weight (provide a range if necessary )
60
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Blood
- Symptom - Bleeding
- Specify - Bright Red Blood
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On January 14, 2010 the dog became anorexic and intermittently lame. On January 15, 2010 the owner took the dog to the veterinarian. On January 16, 2010 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended the owner have the veterinarian call the APSS.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
On January 19, 2010 an APSS technician contacted the owner to follow up the case. The owner stated that the dog died at the veterinary clinic on January 16, 2009, after the APSS consultation.