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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5519

2. Registrant Information.

Registrant Reference Number: 182458

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.

Domestic Animal

4. Date registrant was first informed of the incident.

02-MAY-07

5. Location of incident.

Country: UNITED STATES

Prov / State: ARIZONA

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. 4822-473

Product Name: Raid Ant Killer 16 -17.5 oz

  • Active Ingredient(s)
    • PERMETHRIN
      • Guarantee/concentration .2 %
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration .26 %
    • PYRETHRINS
      • Guarantee/concentration .13 %

7. b) Type of formulation.

Other (specify)

Aerosol

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).

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

70

lbs

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

  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Death
  • Renal System
    • Symptom - Renal failure

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

3

Day(s) / Jour(s)

15. Outcome of the incident

Not recovered / Non rétabli

16. How was the animal exposed?

Other / Autre

specify Clearly defined point of exposure or direct contact with pesticide or pesticide treated surface is not evident and based on speculation.

17. Provide any additional details about the incident

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

5/2/2007 Caller's husband was using the product outside the house on an ant hill and on the patio 2 days ago. The dog was outside when he was spraying. The dog may have licked the patio but no exposure was witnessed. Yesterday, the dog had stopped eating and drinking. Dog is drinking some today but still not eating. 5/24/2007 Follow-up with owner. Dog was diagnosed with renal failure by the DVM and eventually died after three days of hospitalization. The DVM determined that the dog¿¿¿s illness was not related to the pesticide.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. 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.Clearly defined point of exposure or direct contact with pesticide or pesticide treated surface is not evident. Even had casual contact with treated surface occurred, such a profound illness would not be expected. Treating veterinarian had also ruled out involvement of this pesticide.