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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2375

2. Registrant Information.

Registrant Reference Number: 110064168

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.

26-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

25-MAY-11

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. 28293-271-270

Product Name: Adams Plus Yard Spray

  • Active Ingredient(s)
    • PERMETHRIN
      • Guarantee/concentration 2.5 %

7. b) Type of formulation.

Liquid

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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6.0

7. Weight (provide a range if necessary )

10.1

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Vomiting
    • Symptom - Diarrhea
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • 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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

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

On May 25, 2011 the owner noticed the dog was lethargic and had vomiting and diarrhea. On May 26, 2011, the dog had a seizure. That morning, the owner took the dog to the emergency veterinarian, where the dog was given diazepam. The owner decided to transfer the dog to his regular veterinary facility shortly after. On May 26, 2011 the emergency veterinarian contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that dogs tolerate pyrethroids well, that the percentage of the product the dog was exposed to rarely presents a problem, and that once the product has dried it is not a problem. The APSS veterinarian also stated that since the yard was sprayed 48 hours ago, and if the yard was dry before the dog had access to it, no problems were expected and other etiologies should be ruled out. The APSS veterinarian recommended providing a diagnostic evaluation, supportive and symptomatic care, and to call 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

The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On May 31, 2011 an APSS contacted the emergency veterinarian to update the case and was told the dog had died on May 26, 2011, but were not sure of the details regarding the body or time of death. On June 6, 2011 an APSS assistant contacted the emergency veterinarian to try to determine the time of death, and the emergency veterinarian stated the dog died around 10:00 a.m. on May 26, 2011.