Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-4563

2. Registrant Information.

Registrant Reference Number: 187149

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.

15-MAY-07

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

08-MAY-07

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. 25741      PMRA Submission No.       EPA Registration No.

Product Name: RAID WASP & HORNET KILLER 4

• Active Ingredient(s)
  • PERMETHRIN
  • TETRAMETHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

See main noted on subform II

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Chest congestion
  • Symptom - Shortness of breath

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

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.)

5/15/2007 Caller and her husband have sensitivities to products and have underlying medical conditions. 7 days ago the caller's landlord used the product outside their apartment building and ever since the caller has had difficulty breathing and congestion of her chest. Caller's husband has developed what appears to be a skin reaction and hives. No known or direct exposure to spray is reported. No treatments have been conducted. Caller and her husband were instructed to seek medical attention given persistent symptoms. Follow-up was attempted on 5/22 and 5/23. Both times the consumers¿¿¿ phone line was unavailable. Case closed on 5/23 due to difficulty in following up.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

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. With the history as provided by the caller, there is no defined point of direct contact with this particular pesticide. Once the product is sprayed, allowed to settle, and dries, there would be little rerelease of actual material into the air that would cause ongoing respiratory symptoms 7 days after application. Possibility of exposure in this case is negligible, especially since product was applied outside of residence be another user.

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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin
  • Symptom - Hives

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

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.)

5/15/2007 Caller and her husband have sensitivities to products and have underlying medical conditions. 7 days ago the caller's landlord used the product outside their apartment building and ever since the caller has had difficulty breathing and congestion of her chest. Caller's husband has developed what appears to be a skin reaction and hives. No known or direct exposure to spray is reported. No treatments have been conducted. Caller and her husband were instructed to seek medical attention given persistent symptoms. Follow-up was attempted on 5/22 and 5/23. Both times the consumers¿¿¿ phone line was unavailable. Case closed on 5/23 due to difficulty in following up.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

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. With the history as provided by the caller, there is no defined point of direct contact with this particular pesticide. Once the product is sprayed, allowed to settle, and dries, there would be little rerelease of actual material into the air that would cause ongoing respiratory symptoms 7 days after application. Possibility of exposure in this case is negligible, especially since product was applied outside of residence be another user.