Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2133

2. Registrant Information.

Registrant Reference Number: 100052334

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.

27-APR-10

5. Location of incident.

Country: UNITED STATES

Prov / State: TENNESSEE

6. Date incident was first observed.

27-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-333

Product Name: Scratchex Flea and Tick Shampoo for Dogs and Cats

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .24 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .144 %
  • PYRETHRINS
    • Guarantee/concentration .072 %

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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 April 27, 2010 the owner bathed the dog with an unknown amount of the product.

To be determined by Registrant

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

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Lhasa Apso

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2.5

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Abasia

• Gastrointestinal System
  • Symptom - Anorexia

• Renal System
  • Symptom - Urinary incontinence

• General
  • Symptom - Adipsia
  • 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?

Treatment / Traitement

17. Provide any additional details about the incident

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

On April 27, 2010 the owner noticed the dog had abasia, urinary incontinence, adipsia, and was anorexic. Shortly after, the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended taking the dog to the veterinarian to have a physical exam done to try to locate the likely underlying condition, and having the veterinarian calling for information.

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To be determined by Registrant

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

Death

19. Provide supplemental information here

On April 29, 2010 an APSS technician called the owner to follow up the case. The owner stated that the dog died on April 28, 2010 and had taken the dog to the veterinarian where samples were taken for testing. The APSS technician recommended a necropsy, but the owner declined as the dog's body had already been buried. Multiple attempts to update the case with what samples were taken for testing were unsuccessful; therefore, the sample testing is unknown.