Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3902

2. Registrant Information.

Registrant Reference Number: 1184767

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.

12-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

08-JUN-13

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. 16063      PMRA Submission No.       EPA Registration No.

Product Name: Raid Flying Insect Killer 350 g

• Active Ingredient(s)
  • D-CIS, TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PIPERONYL BUTOXIDE
  • TETRAMETHRIN

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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. - 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: Female

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Pain
  • Symptom - Red eye

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

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

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

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.)

On June 12, 2013 consumer reported that while spraying product near her door on June 8, she tasted some of the product in her mouth so she assumed the spray got onto her face. She denies experiencing any symptoms with her eye at the time. At the time of exposure, however, she gargled with water and applied artificial tears to her eyes. She states that on the following day, she had pain and redness in her eye. The consumer reports that she suffers from a chronic form of leukemia and has a history of problems with here eyes, particularly dry eyes. She also has a history of seasonal allergies. She continued to treat herself with OTC eye drops as well as Benadryl. After follow-up with the consumer on June 14, it was discovered the she saw a physician on June 13 where she was diagnosed with inflammation that the physician thought may have been caused by the Raid. She was prescribed prescription antibiotic eye drops.

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 with the history provided exactly how eye exposure to this product may have occurred. The patient's clinical course is atypical. Typically, if eye exposure to insecticide spray occurs, immediate eye irritation occurs. Such eye irritation is typically transient in nature and abates within 1-2 hours following decontamination. It does not appear that this patient ever pursued proper irrigation of the eye if she believes an actual exposure occurred.