Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2926

2. Registrant Information.

Registrant Reference Number: 180110511

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-JUN-18

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

29-JUN-18

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. 270-373

Product Name: Just One Bite II Bar 16 Oz For Use In And Around Agricultural Building

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Unknown
  • BROMADIOLONE
    • Guarantee/concentration .005 %
  • DENATONIUM BENZOATE
    • Unknown

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

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

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

Dog / Chien

3. Breed

Labrador Retriever Mix

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.92

7. Weight (provide a range if necessary )

22.0

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Melena

• General
  • Symptom - Lethargy
  • Symptom - Death

12. How long did the symptoms last?

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

On June 28, 2018, the owner suspects that the dog got a few licks of this product. On the evening of June 29, 2018, the dog developed anorexia. On the morning of June 30, 2018, the dog developed dark feces (melena) and lethargy. The owner then contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated that the risk is for a coagulopathy. The APSS assistant recommended the owner take the dog to a veterinarian, have the veterinarian call for information, and to get the dog started on vitamin K1.

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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 an unknown likelihood of causing the clinical situation. On July 1, 2018, the owner contacted the APSS to follow up on the case. The owner stated that on the evening of June 30, 2018, the dog died before the owner could take her to a veterinarian. At the time of this report, a necropsy is not pending.