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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5936

2. Registrant Information.

Registrant Reference Number: 542818

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.

04-OCT-09

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

02-OCT-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)

PMRA Registration No. 24899      PMRA Submission No.       EPA Registration No.

Product Name: Raid Ant, Roach and Earwig Bug Killer 16 Aerosol Canada 350 g

  • Active Ingredient(s)
    • PERMETHRIN
    • PIPERONYL BUTOXIDE
    • PYRETHRINS

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

Dog / Chien

3. Breed

Pomeranian

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

6.00

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

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • Eye
    • Symptom - Tearing
  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify No known direct contact with treated surface occurred.

17. Provide any additional details about the incident

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

10/4/2009 Caller sprayed the product in the house on her bed two days ago. The product was allowed to dry before the dog was allowed in the area. The dog developed vomiting, anorexia, lacrimation, and lethargy 24 hours later. There was no known exposure to the product. Dog was not seen licking or lying on treated surfaces. 11/1/2009 Callback attempted to the original caller. A message was left requesting follow up information. 11/13/2009 Callback attempted to the original caller. There was no answer and no way to leave a message.


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. The product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with dried pesticide residue occurred , the type of illness as reported in this dog would not be expected, especially given that many canine flea adulticides that are applied directly to the animals contain pyrethrin and/or permethrin at much higher concentrations than that used in this product and do not typically cause illness. Secondly, the differential diagnosis for the development of lethargy and vomiting in a dog is diverse and must include many potential etiologies.