Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3156

2. Registrant Information.

Registrant Reference Number: 110089518

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.

14-JUL-11

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

14-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)

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-324

Product Name: Adams Flea And Tick Cleansing Shampoo For Dogs Puppies Cats And Kitten

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .075 %
  • PYRIPROXYFEN
    • Guarantee/concentration .086 %

---

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 July 12, 2011 the owner applied the product to his dog.

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

American Pit Bull Terrier Mix

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.17

7. Weight (provide a range if necessary )

3.0

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Trembling

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Drooling
  • Symptom - Bloody diarrhea

• General
  • Symptom - Death
  • Symptom - Parvovirus infection

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 July 14, 2011 the owner noticed the dog was having seizures, vomiting, trembling, having diarrhea, and drooling. Later that morning, the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that the use of flea and tick shampoos as per label directions is not expected to cause significant clinical signs and that the concentration of active ingredients is typically quite low, so even ingestion of the agent via licking does not pose a significant threat of toxicity. The APSS veterinarian also stated that licking the agent off the fur may cause a taste reaction that typically resolves by feeding a taste treat. The APSS continued by stating that even the off-label use of the agent in this case was not expected to cause significant signs and that the signs the patient was exhibiting were not consistent with the use of the product. The APSS assistant recommended that the owner take the dog 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 the afternoon of July 14, 2011 the owner's regular veterinarian called the APSS to update the case. The regular veterinarian stated that the owner brought the dog into the vet that day and that the dog had recently developed bloody diarrhea. The regular veterinarian also stated that the dog had been given a fecal Parvovirus test, and had tested positive. The APSS veterinarian recommended that the regular veterinarian provide symptomatic and supportive care. On July 21, 2011 an APSS assistant contacted the regular veterinarian to update the case. The regular veterinarian stated that no symptomatic or supportive care had been provided and that the dog had died on July 18, 2011. A necropsy was not available.