Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-5026

2. Registrant Information.

Registrant Reference Number: 386912

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.

03-OCT-08

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

19-SEP-08

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. 18449      PMRA Submission No.       EPA Registration No.

Product Name: Raid Liquid Ant Killer 100 ml (Canada)

• Active Ingredient(s)
  • BORAX

---

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

DSH

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

15

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Constipation

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Weight loss

12. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Other / Autre

specify No defined point of exposure was witnessed. Product was simply used in residence where cat lived.

17. Provide any additional details about the incident

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

10/3/2008 Owner reports having used product in his trailer home on occasion for the past few months as a crack and crevice spray He does not recall exact dates. Recently, his cat stopped eating, started losing weight, and stopped defecating. He has also been lethargic. Caller is unable to relate how the cat would have been exposed to the material. He never saw that cat physically touching the areas where product was applied. The cat has been to the vet hospital but no cause has been determined. 10/22/2008 Follow-up call completed. Owner states that the cat has recovered. Veterinarian treated the cat with famotidine as the cat was suspected of suffering from a GI ulcer. DVM ruled out involvement of the pesticide.

---

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Moderate

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.