Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4072

2. Registrant Information.

Registrant Reference Number: 664470

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.

19-JUL-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-JUL-10

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. 16063      PMRA Submission No.       EPA Registration No.

Product Name: Raid Flying Insect Killer Canada Only 350 g

• Active Ingredient(s)
  • D-CIS, TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • 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.

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.

System

• Respiratory System
  • Symptom - Respiratory congestion
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

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

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)

Application

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.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Caller sprayed product in her basement on July 16. She states that she immediately developed respiratory irritation and congestion after spraying. The symptoms have not improved or worsened since then. She does states she has a prior history of allergies and asthma. She eventually saw her doctor who was unable to provide a definitive cause for her symptoms. She was prescribed an unspecified inhaler which helped her symptoms improve. 7/20/2010 Callback to the original caller for follow up information. The caller was evaluated by a doctor. Caller is unsure of the diagnosis. Caller was prescribed an unknown inhaler for treatment. The irritation and congestion have been improving with treatment.

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. There are several environmental factors that may affect a patient¿s underlying asthma condition not excluding airborne chemical sprays, although in this case, there does not appear that the patient was directly exposed to liquid airborne spray. Sometimes, what is perceived as an unpleasant odor may affect an asthma condition, especially if the patient develops a significant amount of anxiety related to their exposure to the odor.