Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-3223

2. Registrant Information.

Registrant Reference Number: 344675

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.

10-JUL-08

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

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)

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PMRA Registration No. 20796      PMRA Submission No.       EPA Registration No.

Product Name: Raid House and Garden Bug Killer 450 g (Canada)

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • PIPERONYL BUTOXIDE
  • 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. - 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?

Yes

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Edema

• Skin
  • Symptom - Rash
  • Symptom - Tingling skin

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?

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?

>3 days <=1 wk / >3 jours <=1 sem

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.)

7/10/2008 Caller states that her son developed a rash on his face an unspecified period of time after he entered and area of the home where the pesticide had been applied an unspecified period of time previously. There was no known direct skin contact with the spray or a surface treated with the spray. The patient was diagnosed with an allergic reaction to an unknown material and treated with diphenhydramine and topical hydrocortisone cream. An attempt at following up with the original reporter was made on 7/24/2008 and again on 7/28/2008 with voice mail messages being left both times. The original reporter did not return these messages. This case has been closed.

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. The product use history as well as that of the patient does not indicate that any specific instance of skin contact with this product occurred. If the suggestion is being made that the patient could suffer an allergic reaction by simply entering a room that had the product sprayed in it sometime previously, then the clinical expectation would be dermal manifestations would not be limited to the facial region, but occur in areas all over the body. The differential diagnosis for a skin condition of this nature would include multiple potential etiologies which, in addition to this product, include such factors as plant allergens, poison ivy, poison oak, food, infectious pathogens, heat exposure, insect bites, etc. Skin patch testing would be required before labeling this product as the causative agent.