Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2126

2. Registrant Information.

Registrant Reference Number: 478450

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.

28-MAY-09

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

25-JUN-09

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.       PMRA Submission No.       EPA Registration No. 4822-513

Product Name: Raid Flying Insect Killer Formula 6 Indoor/Outdoor 15oz

• Active Ingredient(s)
  • D-CIS, TRANS ALLETHRIN
    • Guarantee/concentration .1 %
  • PERMETHRIN
    • Guarantee/concentration .1 %
  • TETRAMETHRIN
    • Guarantee/concentration .35 %

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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. - 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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• Respiratory System
  • Symptom - Pneumonia
  • Symptom - Shortness of breath

4. How long did the symptoms last?

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

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

3

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

Application

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

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

5/28/2009 Caller sprayed the product inside of the home four days ago. She does not recall ever getting of the spray on her or inhaling the spray directly. Later in the evening, caller developed nausea and felt short of breath. The following day caller's shortness of breath worsened, and caller was taken to the hospital by ambulance. Caller was intubated and hospitalized for bacterial pneumonia for three days. Caller was given antibiotics, oxygen, and intravenous fluids. Caller reports that she has used Raid products in the past without problems

To be determined by Registrant

14. Severity classification.

Major

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 description of events in this case, there is nothing to suggest that the patient suffered a direct inhalational exposure to the aerosol spray. Furthermore, if inhalation exposure to the spray had occurred, the onset of respiratory symptoms would have been much more immediate than depicted in this case where symptoms began several hours later and did not peak in intensity until the following day. Finally, this patient was diagnosed and treated for bacterial pneumonia in the hospital, thus it would appear that the cause of this patient's illness is infectious in its origins rather than chemical.