Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-8098

2. Registrant Information.

Registrant Reference Number: 160180873

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.

05-DEC-16

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 270-324

Product Name: Adams Flea and Tick Cleansing Shampoo for Cats for Cats and Kittens

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .75 %
  • PYRETHRINS
    • Guarantee/concentration .075 %
  • PYRIPROXYFEN
    • Guarantee/concentration .086 %

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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).

Between November 12, 2016 and November 18, 2016 the owner applied the product onto the cat for treatment.

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

Medical Professional

2. Type of animal affected

Cat / Chat

3. Breed

Siamese

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7.0

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

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?

Treatment / Traitement

17. Provide any additional details about the incident

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

Between November 26, 2016 and December 1, 2016 the cat died. On December 5, 2016 the attending veterinarian called the Animal Product Safety Service (APSS). The APSS veterinarian stated concern with this exposure is for taste reactions (hypersalivation, vomiting); dermal hypersensitivity reactions (pruritus, behavior changes, restlessness) and lethargy. The APSS veterinarian also stated the time frame and clinical signs do not fit with exposure to this product. The APSS veterinarian recommended a necropsy, but it was not possible (as the cat had passed away at home about a week prior to them reporting it; they took the cat home).

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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. A follow up was not performed, because additional information was not expected.

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Cat / Chat

3. Breed

Siamese

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

7

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

• General
  • Symptom - Death

• Skin
  • Symptom - Discolouration
  • Specify - yellow tint

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

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

Between November 26, 2016 and December 1, 2016 the cat had developled yellow tint to the skin and was lethargic a week after exposure. On December 5, 2016 the attending veterinarian called the Animal Product Safety Service (APSS). The APSS veterinarian stated concern with this exposure is for taste reactions (hypersalivation, vomiting); dermal hypersensitivity reactions (pruritus, behavior changes, restlessness) and lethargy. The APSS veterinarian also stated the time frame and clinical signs do not fit with exposure to this product. On 12/02/2016, DVM started animal on doxycline, prednisolone, and ran blood work. DVM stated that the animal had low serum sodium, elevated serum alkaline phosphate, elevated serum amylase, and elevated serum bilirubin total.

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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 not related likelihood of causing the clinical situation. A follow up was not performed, because additional information was not expected.