Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5690

2. Registrant Information.

Registrant Reference Number: 100142515

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-NOV-10

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

03-NOV-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. 270-341

Product Name: Adams Flea and Tick Shampoo for Dogs Puppies Cats Kittens

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .51 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.5 %
  • PYRETHRINS
    • Guarantee/concentration .15 %

---

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 November 2, 2010 the owner bathed the puppy with the product.

To be determined by Registrant

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

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Rat Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.173

7. Weight (provide a range if necessary )

1.5

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

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• General
  • Symptom - Lethargy
  • Symptom - Vocalizing

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Respiratory System
  • Symptom - Dyspnea
  • Symptom - Apnea

• Eye
  • Symptom - Other
  • Specify - Eyes Rolling Back

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

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 November 3, 2010 the puppy became lethargic, ataxic, started vocalizing, developed dyspnea and apnea, so the owner rubbed Vicks vapor rub onto the puppy and provided the puppy with Pedialyte. Later that morning, the owner noticed the cat's eyes were rolling back. Later that day, the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated if the puppy inhaled, or aspirated some of the shampoo, there is a potential for pulmonary edema. and would also be concerned about potential for other etiologies. The APSS veterinarian recommended taking the puppy to the veterinarian and have the veterinarian call for information, as this puppy is too sick to treat at home. The APSS veterinarian also recommended calling back with questions.

---

To be determined by Registrant

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

Death

19. Provide supplemental information here

On November 5, 2010 an APSS assistant called the owner to follow up the case. The owner's fiancee stated that the puppy died on November 5, 2010, but could not provide any additional information.