Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-5419

2. Registrant Information.

Registrant Reference Number: 1218363

Registrant Name (Full Legal Name no abbreviations): S. C. Johnson and Son, Limited

Address: 1 Webster Street

City: Brantford

Prov / State: Ontario

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.

01-AUG-13

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

31-JUL-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. 27106      PMRA Submission No.       EPA Registration No.

Product Name: Raid Ant Roach and Earwig Bug Killer 16A 350g

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

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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. - 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 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

• Cardiovascular System
  • Symptom - Hypertension
  • Symptom - Palpitations

• Gastrointestinal System
  • Symptom - Dry mouth

4. How long did the symptoms last?

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

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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.)

8/1/2013 Caller sprayed product last night in the home behind the stove, refrigerator, freezer, and washer. About 2 hours later, caller developed chest palpitations and a dry mouth. Caller believes this may be due to his previously existing anxiety disorder. The symptoms resolved overnight. Callback was completed with the original caller on 8/8/2013. Caller states that he developed blood pressure problems over the past 4 days, and saw his doctor this morning. He was given blood pressure medication, and states that his high blood pressure has resolved.

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. When considering the body of regulatory data and post-marketing data as well as the weight of scientific peer reviewed evidence on the active ingredient used in this product a definitive causal relationship cannot be established. The product use history lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this product occurred during application, the type of signs and symptoms reported by this patient are not consistent with the toxicological profile of the ingredients used in this product. This patient has a prior history of an anxiety disorder which would offer a reasonable clinical explanation for the appearance of the reported signs and symptoms.