Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2643

2. Registrant Information.

Registrant Reference Number: 120093498

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.

08-JUL-12

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

03-JUL-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. 270-348

Product Name: Adams Water Based Flea And Tick Mist For Dogs Puppies Cats Kittens

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 2 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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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: Res. - In Home / Rés. - à l'int. maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

On July 1, 2012 and again on July 2, 2012 the owner sprayed the product onto a sheet on the dog's bed, allowed it to dry, and crumpled the sheet before putting it back on the dog's bed.

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

Pomeranian Mix

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

17.0

7. Weight (provide a range if necessary )

17.0

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • 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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

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

Sometime between July 2 and July 4, 2012 the owner observed that the dog had died. On July 8, 2012 the owner contacted the Animal Poison Control Center (APSS) to obtain help. The APSS veterinarian stated that given the exposure the owner described, no signs would be expected at all. The APSS veterinarian recommended that the owner have his veterinarian call for information and to provide additional information. A necropsy was not available because the dog's body had been cremated.

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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 an unknown likelihood of causing the clinical situation. On the afternoon of July 8, 2012 the owner called the APSS to obtain contact information for the product's manufacturer. The APSS veterinarian gave the owner the phone number of the product's manufacturer.