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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5520

2. Registrant Information.

Registrant Reference Number: 193027

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.

31-MAY-07

5. Location of incident.

Country: UNITED STATES

Prov / State: TENNESSEE

6. Date incident was first observed.

24-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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 4822-469

Product Name: OFF! Powerpad Lamp Refill

  • Active Ingredient(s)
    • D-CIS, TRANS ALLETHRIN
      • Guarantee/concentration 22 %

7. b) Type of formulation.

Other (specify)

Solid pad

Application Information

8. Product was applied?

No

9. Application Rate.

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).

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

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.58

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • Eye
    • Symptom - Tearing
  • Gastrointestinal System
    • Symptom - Fecal incontinence
  • Renal System
    • Symptom - Urinary incontinence
  • Respiratory System
    • Symptom - Coughing
  • General
    • Symptom - Death

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?

4

Hour(s) / Heure(s)

15. Outcome of the incident

Not recovered / Non rétabli

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

5/31/2007Caller's 50 lb dog chewed up one pad 1 week ago. Caller says the pad was not consumed, it was just chewed up. Dog developed runny eyes and coughing up phlegm 2 days later. Dog then developed urinary and fecal incontinence within 4 hours of initial sxs. He had a flea collar applied 2 months ago. Caller consulted a DVM, but the dog died while there without any diagnostic testing performed. The cause of death is unknown. No necropsy was performed.


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.Amount allethrin in these pads is not high enough in concentration to cause anything other than mild gastrointestinal upset in a 50 lb dog that only chewed on the pad. Also, such symptoms would be expected to occur within 1-2 hours of exposure, not 2 days later.