Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-2059

2. Registrant Information.

Registrant Reference Number: 2021-US-003840

Registrant Name (Full Legal Name no abbreviations): Farnam Companies, Inc.

Address: 301 W. Osborn Road

City: Phoenix

Prov / State: Arizona

Country: United States of America

Postal Code: 85013

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

02-MAR-21

5. Location of incident.

Country: UNITED STATES

Prov / State: TENNESSEE

6. Date incident was first observed.

01-MAR-21

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. 270-343

Product Name: Farnam Flys-Off Insect Repellent for Dogs and Cats

• Active Ingredient(s)
  • DI-N-PROPYL ISOCINCHOMERONATE
    • Guarantee/concentration .5 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .5 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.5 %
  • PYRETHRINS
    • Guarantee/concentration .15 %

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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).

Please refer to field 13 on Subform II or field 17 on Subform III for a detailed description regarding application.

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

Unknown

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?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Cardiovascular System
  • Symptom - Other
  • Specify - Unspecified disorder, owner performed CPR

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

On 01 Mar 2021, the animal owner applied the product to the cat. Approximately 20 minutes later the animal owner performed CPR on the cat for unspecified reasons. The cat was brought to a veterinarian the same day and it is unknown if the cat was hospitalized or any treatments were performed. The cat died on 01 Mar 2021. Information was relayed by the animal owner via customer service for reporting and documentation purposes. Animal owner had disconnected call and was unable to be contacted for additional clarification and information. No further information is 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

Assessment: This product has wide margin of safety and is not expected to cause either severe clinical signs necessitating CPR or death. Mild dermal irritation is possible following topical use. If ingested, mild self-limiting GI irritation leading to vomiting, anorexia, and adipsia may occur. Other causes should be considered including underlying disease, stress response, trauma and other underlying disease. Additional information from the animal owner about product application, development of clinical signs, veterinarian exam and diagnostic findings, treatments (if any) performed, and necropsy may have provided additional insight; however, these are not available. The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and cannot form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.