Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1882

2. Registrant Information.

Registrant Reference Number: 120057577

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-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

30-APR-12

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. 270-294

Product Name: Flea Halt Water Base Flea And Tick Spray For Dogs

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration .1 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PYRETHRINS
    • Guarantee/concentration .05 %

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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 April 30, 2012 the owner sprayed the dog with the product to prevent fleas.

To be determined by Registrant

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

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.08

7. Weight (provide a range if necessary )

50.0

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

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

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Ataxia

• General
  • Symptom - Weakness

• Gastrointestinal System
  • Symptom - Other
  • Specify - Tongue Protrusion

• 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?

Yes

14. b) How long was the animal hospitalized?

Unknown

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 April 30, 2012 the owner noticed that the dog was lethargic, ataxic, and weak. On May 2, 2012 the owner noticed that the dog's lethargy had become severe, her ataxia had worsened, she was weaker, and her tongue was protruding. At that time, the owner took the dog to the veterinarian, where an injection of penicillin was possibly administered. On the morning of May 4, 2012 the owner bathed the dog. A short time later, the owner observed that the dog died. Later that day, the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that the dog's signs were not consistent with the use of the product and that if the dog had licked the product, a mild bad taste reaction might have been seen. The APSS technician recommended that the owner call her veterinarian to discuss the medical findings and a possible necropsy and to call back with questions.

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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 not considered to be related to causing the clinical situation and that heartworm disease was considered to have an unknown likelihood of causing the clinical situation. A necropsy was not available. A follow up was not performed, because additional information was not expected.