Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1305

2. Registrant Information.

Registrant Reference Number: 1032866

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

Packaging Failure

4. Date registrant was first informed of the incident.

29-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

25-JUL-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)

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PMRA Registration No. 27324      PMRA Submission No.       EPA Registration No.

Product Name: OFF! familycare Spray Insect Repellent Summer Splash 175mL - Canada

• Active Ingredient(s)
  • DEET (N,N-DIETHYL-M-TOLUAMIDE) PLUS RELATED ACTIVE TOLUAMIDES (ORTHO & PARA ISOMERS)

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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: Personal use / Usage personnel

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?

No

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

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Tactile sensory abnormality

• Skin
  • Symptom - Burns (2nd or 3rd degree)
  • Symptom - Tingling skin

4. How long did the symptoms last?

>1 mo and <= 2mos / >1 mois et < = 2mois

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.

Skin

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.)

August 29, 2012 Consumer called to report an incident that occurred at his cabin on July 20th. When it was pressed down, it would not pop back up. Consumer states that the pump spray device on this bottle had broken by some unknown means previously. The caller had not actually purchased the product but had borrowed it from his brother. The brother did not recall how the pump spray had become broken. Because the pump spray was not working, a family member had unscrewed the enclosure so that it may be poured into the caller's hands in order to spread it around the skin on his body. While the product was being poured into his hands, it trickled down between his fingers and landed near a campfire which was approximately 1.5 ft away. The campfire then flared up and caused the caller's hands top catch fire. Caller immediately jumped into a nearby lake in order to put his hands in the lake water. He was then transported to a local hospital. At hospital he was diagnosed with 2nd and 3rd degree burns. He required aggressive burn care that included surgical debridement of the burn wounds in the ER. He was not admitted to the hospital but he required aggressive outpatient care for an extended period of time. His hands were bandaged for 2.5 weeks and required regular applications of antibiotic. He consulted with a plastic surgeon and it was determined that he will not require skin graphs. He has lost the ability to sense temperature changes with his hands and he has a persistent tingling sensation. The burn doctor had indicated these are normal symptoms following serious burns and that they should gradually dissipate. He was told that his hands appear to be healing nicely and no further complications are expected.

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.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Spray Bottle / Flacon pulvérisateur

2. Did packaging failure occur during?

Other

specify The consumer did not know how the pump spray device broke.

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

August 29, 2012Consumer called to report an incident that occurred at his cabin on July 20th. When it was pressed down, it would not pop back up. Consumer states that the pump spray device on this bottle had broken by some unknown means previously. The caller had not actually purchased the product but had borrowed it from his brother. The brother did not recall how the pump spray had become broken. Because the pump spray was not working, a family member had unscrewed the enclosure so that it may be poured into the caller's hands in order to spread it around the skin on his body. While the product was being poured into his hands, it trickled down between his fingers and landed near a campfire which was approximately 1.5 ft away. The campfire then flared up and caused the caller's hands top catch fire. Caller immediately jumped into a nearby lake in order to put his hands in the lake water. He was then transported to a local hospital. At hospital he was diagnosed with 2nd and 3rd degree burns. He required aggressive burn care that included surgical debridement of the burn wounds in the ER. He was not admitted to the hospital but he required aggressive outpatient care for an extended period of time. His hands were bandaged for 2.5 weeks and required regular applications of antibiotic. He consulted with a plastic surgeon and it was determined that he will not require skin graphs. He has lost the ability to sense temperature changes with his hands and he has a persistent tingling sensation. The burn doctor had indicated these are normal symptoms following serious burns and that they should gradually dissipate. He was told that his hands appear to be healing nicely and no further complications are expected.

For Registrant use only

5. 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.