Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2224

2. Registrant Information.

Registrant Reference Number: 120070925

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.

29-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

6. Date incident was first observed.

26-MAY-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. 270-349

Product Name: Adams Plus Pyrethrin Dip

• Active Ingredient(s)
  • DI-N-PROPYL ISOCINCHOMERONATE
    • Guarantee/concentration 1.94 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 5.7 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 3.74 %
  • PYRETHRINS
    • Guarantee/concentration .97 %

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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 May 26, 2012 the owner applied the dip product to the cat.

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

Cat / Chat

3. Breed

Maine Coon

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

3.0

7. Weight (provide a range if necessary )

10.0

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Respiratory System
  • Symptom - Difficulty Breathing
  • Specify - Abnormal Breathing

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Respiratory System
  • Symptom - Coughing

• General
  • Symptom - Listless
  • Symptom - Death

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?

Treatment / Traitement

17. Provide any additional details about the incident

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

On May 26, 2012, immediately after the owner applied the dip product to the cat, the owner noticed that the cat was breathing abnormally, ataxic, coughing, and listless. The owner immediately rinsed the cat's coat and skin and called her veterinarian, but the cat died several minutes later. On May 29, 2012 the owner contacted the Animal Product Safety Service (APSS) to obtain help. The APSS veterinarian stated that significant signs from the diluted dip product would not be expected, and that a bad taste reaction could be seen in some cases. The APSS veterinarian also stated that she would suspect either acute anaphylaxis or an underlying cardiac condition, and a necropsy would need to be done to determine the cause of death. The APSS veterinarian recommended that the owner have a necropsy done if the body was available and have her veterinarian call for information regarding a necropsy, if applicable.

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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 low likelihood of causing the clinical situation and that anaphylactic shock and cardiovascular disease were considered to have an unknown likelihood of causing the clinical situation. Later on May 29, 2012 the owner called the APSS to decline a necropsy for the cat.