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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0365
2. Registrant Information.
Registrant Reference Number: 140123997
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.
30-SEP-145. Location of incident.
Country: UNITED STATES
Prov / State: ALABAMA
6. Date incident was first observed.
20-SEP-14Product 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 Cats and Kittens
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- Guarantee/concentration .75 %
- PYRETHRINS
- Guarantee/concentration .075 %
- PYRIPROXYFEN
- Guarantee/concentration .086 %
- PIPERONYL BUTOXIDE
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 September 17, 2014 the owner bathed the kittens with the product, diluted with water and liquid dish washing detergent (LDWD).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
Cat / Chat
3. Breed
Domestic Mediumhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.077
7. Weight (provide a range if necessary )
1.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Weakness
- Symptom - Hypothermia
- 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 September 20, 2014 the kitten developed lethargy, weakness, and hypothermia. On September 22, 2014 the kitten died. On September 30, 2014 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated although it is off label use death is not expected. The APSS veterinarian provided information and recommended a necropsy, which was unavailable.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Product was not considered to be related to causing the clinical situation. The APSS veterinarian stated that flea infestation was considered to have a medium likelihood of causing the clinical situation. A follow up was not performed, because additional information was not expected.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Mediumhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.077
7. Weight (provide a range if necessary )
1.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Weakness
- Symptom - Hypothermia
- 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 September 22, 2014 the kitten developed lethargy, weakness, and hypothermia. On September 23, 2014 the kitten died. On September 30, 2014 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated although it is off label use death is not expected. The APSS veterinarian provided information and recommended a necropsy, which was unavailable.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Product was not considered to be related to causing the clinical situation. The APSS veterinarian stated that flea infestation was considered to have a medium likelihood of causing the clinical situation. A follow up was not performed, because additional information was not expected.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Mediumhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.077
7. Weight (provide a range if necessary )
1.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Weakness
- Symptom - Hypothermia
- 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 September 22, 2014 the kitten developed lethargy, weakness, and hypothermia. On September 25, 2014 the kitten died. On September 30, 2014 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated although it is off label use death is not expected. The APSS veterinarian provided information and recommended a necropsy, which was unavailable.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Product was not considered to be related to causing the clinical situation. The APSS veterinarian stated that flea infestation was considered to have a medium likelihood of causing the clinical situation. A follow up was not performed, because additional information was not expected.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Mediumhair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.077
7. Weight (provide a range if necessary )
1.0
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Weakness
- Symptom - Hypothermia
- 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 September 22, 2014 the kitten developed lethargy, weakness, and hypothermia. On September 26, 2014 the kitten died. On September 30, 2014 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated although it is off label use death is not expected. The APSS veterinarian provided information and recommended a necropsy, which was unavailable.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Product was not considered to be related to causing the clinical situation. The APSS veterinarian stated that flea infestation was considered to have a medium likelihood of causing the clinical situation. A follow up was not performed, because additional information was not expected.
