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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-7266

2. Registrant Information.

Registrant Reference Number: 219007

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: COLORADO

6. Date incident was first observed.


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.


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

Product Name: Raid Flea Killer 16 oz.4822-73

  • Active Ingredient(s)
      • Guarantee/concentration .98 %
      • Guarantee/concentration 1 %
      • Guarantee/concentration .14 %
      • Guarantee/concentration .063 %

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

Product Name: Raid Flea Killer Plus Carpet and Room Spray 16 oz4822-273

  • Active Ingredient(s)
      • Guarantee/concentration .015 %
      • Guarantee/concentration 1 %
      • Guarantee/concentration 1 %
      • Guarantee/concentration .14 %
      • Guarantee/concentration .063 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Res. - In Home / Rés. - à l'int. 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?


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.


  • Gastrointestinal System
    • Symptom - Bloody stool
  • Skin
    • Symptom - Irritated skin
  • Gastrointestinal System
    • Symptom - Stomach pain
    • Symptom -
    • Specify - Gastrointestinal bleed NOS (not otherwise specified)

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


Day(s) / Jour(s)

7. Exposure scenario


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


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


10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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.)

8/1/2007 1:01:49 PMCaller reports visiting son in (State) about 2 wks ago. During her visit her son apparently had a flea infestation in his home and caller used these 2 products to help in the abatement. She is unable to describe any defined point of exposure other than the incident contact with treated surfaces. She states that about 2 days of using these products she developed abdominal pain and subsequently passed blood in her stool. She was seen at local hospital and hospitalized for about 3 days for a GI bleed. She also reports since returning to her own home she has been experiencing skin irritation which feels like "little bites/stings" to tops of hands and feet, though does not see any visible bite marks. She saw her personal doctor who could not find anything wrong with her skin. Caller has a prior history of hypertension.

To be determined by Registrant

14. Severity classification.


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.Exposure scenario reported in this even is vague. Even had direct contact with treated surface occurred, profound illness such as reported in this case would not be expected based on what is known regarding the toxicological profile of the active ingredients used in this pesticide at application concentrations. Both products contains pyrethroid compounds which even in the setting of acute systemic poisoning are not typically associated with gastrointestinal bleeds as a primary mechanism of toxicity.