Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5255

2. Registrant Information.

Registrant Reference Number: 693759

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.

17-SEP-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 26909      PMRA Submission No.       EPA Registration No.

Product Name: Raid EarthBlends Multi-Bug Killer Aerosol 350g - Canada

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• Gastrointestinal System
  • Symptom - Sore throat

• Ear
  • Symptom - Tinnitus
  • Specify - Tinnitus

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Respiratory System
  • Symptom - Respiratory irritation

• Skin
  • Symptom - Itchy 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)

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.

Unknown

11. What was the length of exposure?

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

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.)

9/17/2010 Caller sprayed the product in the air in his bedroom 10 days ago and again 4 or 5 days ago. Since the first use, caller has experienced a sore throat, dizziness, ocular irritation, itching, respiratory irritation, and tinnitus. The symptoms improve when he leaves the area, and worsen when he returns. Caller has been evaluated by two doctors. One doctor indicated the product may be the cause and took a blood sample. The second doctor found his breathing to be normal, but suggested he may have pneumonia and should have a chest x-ray. 9/24/2010 Attempted callback to the original caller for follow up. The phone number provided is not in service.

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. It is unclear how or two what extent this patient was exposed this pesticide. If direct inhalation of the spray occurred or dermal contact occurred, then upper respiratory irritation and skin irritation are possible, however, such symptoms are usually transitory in nature and not protracted. The treatment with an antibiotic would suggest more of an infectious etiology.