Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0554

2. Registrant Information.

Registrant Reference Number: 170203066

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.

20-NOV-17

5. Location of incident.

Country: UNITED STATES

Prov / State: CONNECTICUT

6. Date incident was first observed.

12-NOV-17

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. 270-294

Product Name: Flea Halt Water Base Flea And Tick Spray For Dogs Plus Citronella

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration .1 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PYRETHRINS
    • Guarantee/concentration .05 %

---

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 20, 2017 through November 13, 2017, the owner applied the product to the dog weekly as prevention.

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Rottweiler

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5.0

7. Weight (provide a range if necessary )

216.0

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

10. Time between exposure and onset of symptoms

>1 mo <=2 mos / > 1 mois < = 2 mois

11. List all symptoms

System

• Skin
  • Symptom - Other
  • Specify - Application Site Burn
  • Symptom - Hair loss
  • Symptom - Discolouration
  • Specify - discoloration of the coat

• Respiratory System
  • Symptom - Wheezing

• Nervous and Muscular Systems
  • Symptom - Depression

• General
  • Symptom - Other
  • Specify - Dry Mucous Membranes
  • Symptom - Death
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

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 November 12, 2017 the dog developed application site burns, alopecia (hair loss), and discoloration of the coat. On November 16, 2017 the dog developed wheezing, depression, and dry mucous membranes. The owner then took the dog to the regular veterinarian who provided fluid therapy. On November 20, 2017 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that dogs tolerate pyrethroids well and that no life threatening signs are expected. The APSS veterinarian also stated that pyrethroids can cause a pins and needles sensation or hyperesthesia, resulting in reluctance to move, mild tremors, paw shaking, ear twitching or facial fasciculations and that some dogs will develop erythema and pruritis as well. The APSS veterinarian stated that they did not expect wheezing, or respiratory signs from product exposure. The APSS veterinarian recommended the owner have the regular veterinarian call for information. On December 14, 2017 the company followed up on the case and the owner stated that the dog passed away on December 2, 2017. A necropsy was rejected as the dog had already been buried.

---

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.