Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5959
2. Registrant Information.
Registrant Reference Number: 645429
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.
11-JUN-10
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
06-JUN-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)
PMRA Registration No. 27185
PMRA Submission No.
EPA Registration No.
Product Name: Raid EarthBlends Ant + Earwig Dust (225g) Canada
- Active Ingredient(s)
- SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.50
7. Weight (provide a range if necessary )
50.00
lbs
8. Route(s) of exposure
Oral
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
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
12. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
13. Was medical treatment provided? Provide details in question 17.
No
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
6/11/2010 Caller reports that her dog chewed on a container of the product five days ago. The dog developed anorexia and vomiting the following day. The dog has lost weight since symptoms developed. Caller is now at the veterinarian with the dog for an evaluation. 7/4/2010 Attempted callback to the original caller. A message was left requesting follow up information. 7/9/2010 Callback to the original caller for follow up information The veterinarian said the dog was dehydrated from vomiting, and advised making sure the dog gets plenty of fluids at home. No treatments were applied. Caller made sure the dog had plenty of fluids at home, and the dog was asymptomatic a few days later.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Significant ingestion of both the container and the contents my product self-limiting gastrointestinal distress and secondary dehydration if there is much insensible fluid loss.