Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-0339
2. Registrant Information.
Registrant Reference Number: 100160564
Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.
Address: 301 West 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.
15-DEC-10
5. Location of incident.
Country: UNITED STATES
Prov / State: SOUTH CAROLINA
6. Date incident was first observed.
14-DEC-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
Black Mouth Cur
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
30
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
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Retching
- Symptom - Vomiting
- Symptom - Bloody stool
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 December 10, 2010 the puppy became lethargic and anorexic; started retching and vomiting. On December 15, 2010 the owner noticed the puppy had bloody feces, so the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated coagulopathy may occur following significant bromadiolone ingestion. The APSS veterinarian recommended taking the puppy 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 December 20, 2010 an APSS assistant called the owner to follow up the case. The owner stated the puppy had access to the agent on December 10, 2010 and after the APSS consultation, he went to take the puppy to the veterinarian, but the puppy died. The owner also stated he buried the body, so it was not available for the necropsy recommended by the APSS. The APSS assistant also recommended calling back with questions.