Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-5840

2. Registrant Information.

Registrant Reference Number: 2095078

Registrant Name (Full Legal Name no abbreviations): S.C. Johnson and Son, Limited

Address: 1 Webster Street

City: Brantford

Prov / State: ON

Country: Canada

Postal Code: N3T 5R1

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

Human

4. Date registrant was first informed of the incident.

18-AUG-17

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

18-FEB-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)

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PMRA Registration No. 32435      PMRA Submission No.       EPA Registration No.

Product Name: Raid Max Crawling Insect Bug Killer 4 500g - Canada

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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).

Please refer to field 13 on Subform II or field 17 of 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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Irritated throat

• General
  • Symptom - Other
  • Specify - Hot Flashes

• Nervous and Muscular Systems
  • Symptom - Muscle spasm

• General
  • Symptom - Pain

• Renal System
  • Symptom - Blood in urine

• Respiratory System
  • Symptom - Shortness of breath

• Skin
  • Symptom - Irritated skin

• Gastrointestinal System
  • Symptom - Sore throat

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Poisoning from ingestion of the pesticide

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

8/18/2017 Caller originally states that her daughter got some product on her tongue in the end of March 2017. About 2 days later she developed a sore throat. Her body has a transient burning sensation in various places. Caller alternates between saying her and me regarding symptoms. She has seen a doctor, and blood work was performed. Caller states that the blood was found to be contaminated, but caller was unable to provide details about the contaminant in her blood. 8/21/2017 Call back from the consumer. Caller is still experiencing symptoms, which started a week or 2 after the exposure. Symptoms include skin irritation, blood in urine, muscle spasms, difficulty breathing, and hot flashes. Caller went to the emergency room 2 weeks ago, and to her primary doctor today. She had blood work and x-ray performed, which were within normal limits. 8/23/2017 Attempted call back to the original caller. A message was left requesting follow up.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Any relationship between the use of this product and the insidious development of the complications reported in this case is inconceivable and lacks biological plausibility. Even had casual or incidental contact with this product occurred, such illness would be unexpected and is not consistent with the toxicological profile of this product.. 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 can not 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.