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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-1472

2. Registrant Information.

Registrant Reference Number: 100040347

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.

03-APR-10

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

03-APR-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 Rat and Mouse Bait Bar

  • 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

Canine Domestic Unspecified

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Collapse
  • Gastrointestinal System
    • Symptom - Rectal hemorrhage
  • Respiratory System
    • Symptom - Laboured breathing
  • General
    • Symptom - Other
    • Specify - Dark gums (Abnormal Mucous Membrane Color)
    • Symptom - Death

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

On April 3, 2010 visitors told an extended family member that the dog had collapsed in the bushes earlier that day and had been laying in the yard for several hours, not moving. Later that day, the dog was found bleeding from her rectum and with labored breathing, so the extended family member contacted the Animal Product Safety Service (APSS). During the APSS consult, the caller stated that the dog's gums were dark in color. The APSS technician recommended taking 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 April 8, 2010 an APSS technician called the extended family to follow up the case. The extended family stated that the dog died shortly after the APSS consultation, and he was not interested in additional consultation.