Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-6050

2. Registrant Information.

Registrant Reference Number: 170132149

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.

01-AUG-17

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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 Cleanser With IGR For Dogs Puppies Cats & 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).

On an unknown date, the owner bathed the cat with this product.

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

Cat / Chat

3. Breed

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

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

Unknown / Inconnu

11. List all symptoms

System

• Renal System
  • Symptom - Urinary incontinence

• Respiratory System
  • Symptom - Dyspnea

• Gastrointestinal System
  • Symptom - Salivating excessively

• General
  • Symptom - Vocalizing
  • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

14. a) Was the animal hospitalized?

Unknown

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

At an unknown date, the cat developed urinary incontinence, dyspnea, hypersalivation, and vocalization. On August 1, 2017 the cat passed away. Shortly after, the owner contacted the Animal Product Safety Service (APSS). While trying to gather information, the owner disconnected from the APSS assistant. The APSS technician stated that mild dermal hypersensitivity from appropriate use of flea and tick shampoo can be seen. The APSS technician also stated that signs should be self-limiting and that death would not be expected.

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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 technician stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. An attempt to update the case was unsuccessful. A necropsy was unavailable because the body was not in adequate condition.