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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4971

2. Registrant Information.

Registrant Reference Number: 503154

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.

16-JUL-09

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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.

Liquid

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Rat Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.5

7. Weight (provide a range if necessary )

16

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
    • Symptom - Parvovirus infection
    • Specify - Diagnosed with Canine Parvovirus
    • Symptom - Lethargy

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?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Provide any additional details about the incident

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

7/16/2009 Caller's spouse sprayed the product on the kitchen floor four days ago. The following day, caller's dog became anorexic and lethargic. The dog had no witnessed exposure to the product. The dog has not been eating or drinking water for three days. 8/3/2009 Callback to the original caller for follow up. The dog was seen by a veterinarian, and was diagnosed with canine parvovirus, a common but severe infectious disease in dogs. The veterinarian gave the caller shots to administer to the dog at home. The dog reacted to the shot and the dog died at home.


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. The treating veterinarian determined an alternative etiology for this illness and ruled out involvement of the pesticide. Parvovirus is a clinically detrimental infectious disease common amongst puppies. The prognosis for survival of parvovirus is typically grave unless intensive care is instituted. Exposure to the product in question does not cause parvovirus in dogs.