Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-3946
2. Registrant Information.
Registrant Reference Number: 180129294
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.
31-JUL-18
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
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. 270-324
Product Name: Adams Flea And Tick Cleansing Shampoo For Dogs Puppies Cats And Kitten
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- Guarantee/concentration .75 %
- PYRETHRINS
- Guarantee/concentration .075 %
- PYRIPROXYFEN
- Guarantee/concentration .086 %
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).
At an unknown date and time, the product was applied to the cat.
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 Unspecified
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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 and time after the product was applied, the cat died. The owner then emailed the company to report the death. The company contacted the Animal Product Safety Service to document the exposure. The APSS technician stated that mild dermal irritation can be seen.
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. A follow up was not performed, because additional information was not expected. At the time of this report, a necropsy is not pending.