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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-2992

2. Registrant Information.

Registrant Reference Number: 160071186

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.

19-MAY-16

5. Location of incident.

Country: UNITED STATES

Prov / State: OREGON

6. Date incident was first observed.

Unknown

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. 270-373

Product Name: Just One Bite II Bar

  • Active Ingredient(s)
    • BROMADIOLONE
      • Guarantee/concentration .005 %

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

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

Between April 21, 2016 and May 19, 2016 the owner applied the bait in her greenhouse.

To be determined by Registrant

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

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Chicken Unspecified

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5.5

7. Weight (provide a range if necessary )

10.0

lbs

8. Route(s) of exposure

Oral

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?

Unknown / Inconnu

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?

Other / Autre

specify Relay

17. Provide any additional details about the incident

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

Between April 28, 2016 and May 12, 2016 the owner found the chicken dead. On May 19, 2016 the owner contacted the Animal Product Safety Service (APSS) as she had seen the chicken eat some of the mice and is concerned about a relay toxicity. The chicken is a laying hen and the owner did consume eggs since the bait was applied. The APSS veterinarian stated the risk for a relay toxicosis is low leading to coagulopathy issues. A necropsy was not available.


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.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Chicken

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5.5

7. Weight (provide a range if necessary )

10.0

lbs

8. Route(s) of exposure

Oral

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?

Unknown / Inconnu

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?

Other / Autre

specify Relay

17. Provide any additional details about the incident

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

On May 18, 2016 the owner found the chicken dead. On May 19, 2016 the owner contacted the Animal Product Safety Service (APSS) as she had seen the chicken eat some of the mice and is concerned about a relay toxicity. The chicken is a laying hen and the owner did consume eggs since the bait was applied. The APSS veterinarian stated the risk for a relay toxicosis is low leading to coagulopathy issues. A necropsy was not available.


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.