Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5050

2. Registrant Information.

Registrant Reference Number: 100126606

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.

28-SEP-10

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

6. Date incident was first observed.

28-SEP-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. 270-348

Product Name: Adams Water-Based Flea and Tick Mist

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 2 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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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 September 27, 2010 the owner applied the product onto the cat.

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

Cat / Chat

3. Breed

Manx

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

14

7. Weight (provide a range if necessary )

4

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Drooling

• General
  • Symptom - Vocalizing

• Nervous and Muscular Systems
  • Symptom - Seizure
  • Symptom - Ataxia

• General
  • Symptom - Death

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?

Treatment / Traitement

17. Provide any additional details about the incident

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

On September 28, 2010 the owner found the cat vocalizing, hypersalivating, ataxic, and having a seizure. The owner then bathed the cat with liquid dish washing detergent. The owner then contacted the Animal Product Safety Service (APSS). The APSS technician relayed the APSS veterinarian's recommendations to take the cat to the veterinarian, have the veterinarian call for information, call the manufacturer with reimbursement questions, and have a diagnostic evaluation done as the cat's signs are inconsistent with the product.

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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 September 28, 2010 the owner contacted the APSS back to discuss reimbursement for veterinary care. The APSS veterinarian again recommended the cat be seen by a veterinarian as soon as possible. On September 30, 2010 an APSS assistant called the owner to follow up the case. The owner stated that he did take the cat to the veterinarian, but the cat passed away on its own at the veterinary clinic. The owner also stated he had asked the attending veterinary clinic to dispose of the body for them. Later on September 30, 2010 an APSS technician called and left a message for the owner regarding necropsy options.