Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3154

2. Registrant Information.

Registrant Reference Number: 110084168

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.

04-JUL-11

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

6. Date incident was first observed.

04-JUL-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-372

Product Name: Just One Bite II Place Pack Pellets

• Active Ingredient(s)
  • BROMADIOLONE
    • Guarantee/concentration .005 %

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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

Miniature Pinscher

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.0

7. Weight (provide a range if necessary )

6.4

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

The dog accidentally ingested some of the product on July 4, 2011, and shortly after the owner called the Animal Product Safety Service (APSS) to obtain help. The APSS technician stated that the risk was for coagulopathy in 3 to 5 days. The APSS veterinarian also stated that a significant hemorrhage could occur that might result in death, but the time frame in this case was not consistent with what would be expected. The APSS technician recommended that the owner induce emesis and call back with the emesis results.

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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

The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On the morning of July 4, 2011 the owner called the APSS, and told the assistant that the dog had not vomited after he attempted to induce emesis. The APSS assistant recommended attempting to induce emesis a second time, per previous instructions, and to call back with the results. On July 6, 2011 an APSS veterinarian called the owner to update the case. The owner stated the dog had died on the morning of July 5, 2011.