Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1303

2. Registrant Information.

Registrant Reference Number: 1032043

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.

28-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

21-AUG-12

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. 29776      PMRA Submission No.       EPA Registration No.

Product Name: Raid Wasp and Hornet Killer 7 400g Canada

• Active Ingredient(s)
  • D-PHENOTHRIN
  • TETRAMETHRIN

---

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. - Out Home / Rés - à l'ext.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

• Gastrointestinal System
  • Symptom - Stomach pain
  • Symptom - Other
  • Specify - Blood in saliva

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

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

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.)

8/28/2012 French Interpreter required. Caller states he began using the product 1-1/2 week ago outdoors. He has been spraying a nest on his balcony. He states spray drift may have gotten onto him. He has used 4 cans of product over he past 10 days. Yesterday he noticed blood in his spit so he stopped using the product. He has not had any coughing or respiratory symptoms. He has had burning in his stomach that he feels is unrelated because he thinks he had this prior to using the sprays. He is asking if this bleeding is from the product. Blood is still present today in his saliva but in lesser quantity. Caller was instructed to see a physician for an immediate evaluation. 9/4/2012 Follow-up was attempted. A message was left requesting that the consumer call back with an update on his status. Consumer has not returned the follow-up call as of 9/18/2012.

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. Any relationship between the use of this product and the development of the complication reported in this case lacks biological plausibility especially given the absence of respiratory symptoms. Based on post-marketing experience with accidental oral exposures to this type of pesticide, oral bleeding is not a consistent or well characterized outcome. It seems more likely this patient's problem may be connected to the stomach problems he had prior to using this pesticide.