Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6547
2. Registrant Information.
Registrant Reference Number: 1213247
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.
24-JUL-13
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
24-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)
PMRA Registration No. 27185
PMRA Submission No.
EPA Registration No.
Product Name: (discontinued) 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?
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Russian Blue
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
8.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Salivating excessively
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
7/24/2013 Caller applied the product in the home yesterday. At the time of application, caller's cat was on the second floor. Today, the cat started sneezing and salivating, and ran out of the house. 7/29/2013 Callback to the original caller for follow up information. The cat was brought to a veterinarian who believes the product got into the cat's sinuses. The symptoms are persisting.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. 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.