Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2661
2. Registrant Information.
Registrant Reference Number: 100063699
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.
21-MAY-10
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
17-MAY-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. 270-348
Product Name: Adams Water Based Flea and Tick Mist for Dogs Puppies Cats Kittens
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration 2 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .75 %
- PYRETHRINS
- Guarantee/concentration .2 %
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 May 17, 2010 the owner sprayed the dog with the product for the first time.
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
Standard Poodle
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2.5
7. Weight (provide a range if necessary )
80
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Salivating excessively
- Specify - hypersalivating
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 May 17, 2010 the dog became lethargic, began hypersalivating, and then collapsed. Shortly later, the dog died. On May 21, 2010 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian recommended a necropsy, having the veterinarian call for information, and calling back with questions. The owner stated a necropsy couldn't be performed as the dog had already been cremated.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation.