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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6588
2. Registrant Information.
Registrant Reference Number: 1202768
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.
09-JUL-135. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
Unknown
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. 27227 PMRA Submission No. EPA Registration No.
Product Name: OFF! PowerPad Mosquito Lamp
- Active Ingredient(s)
- D-CIS, TRANS ALLETHRIN
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?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
7.50
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- Symptom -
- Specify - Pancreatitis
- General
- Symptom - Lethargy
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
3
Day(s) / Jour(s)
15. Outcome of the incident
Recvrd resid.effects/Rétabli séquelles
16. How was the animal exposed?
Other / Autre
specify No exposure was witness and product did not appeared to be tampered with. Exposure is based on speculation by the owner.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
7.9.2013 Caller is a veterinary technician calling from a clinic that have two cats that are anorexic, lethargic, and may have been vomiting. There is a third cat in the home that had the same symptoms previously but have since resolved. The owner had the product out 3 to 4 days ago, but no exposure was witnessed. 7.15.2013 Callback to the original caller for follow up information. One of the cats developed pancreatitis, and the other cat was fine within a few days.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Major
19. Provide supplemental information here
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interviews. 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 insidious development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and 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, such illness would be unexpected and is not consistent with the toxicological profile of this product.
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic shorthair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
7.05
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- General
- Symptom - Lethargy
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify No exposure was witness and product did not appeared to be tampered with. Exposure is based on speculation by the owner.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
7.9.2013 Caller is a veterinary technician calling from a clinic that have two cats that are anorexic, lethargic, and may have been vomiting. There is a third cat in the home that had the same symptoms previously but have since resolved. The owner had the product out 3 to 4 days ago, but no exposure was witnessed. 7.15.2013 Callback to the original caller for follow up information. One of the cats developed pancreatitis, and the other cat was fine within a few days.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interviews. 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 insidious development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and 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, such illness would be unexpected and is not consistent with the toxicological profile of this product.
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- General
- Symptom - Lethargy
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify No exposure was witness and product did not appeared to be tampered with. Exposure is based on speculation by the owner.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
7.9.2013 Caller is a veterinary technician calling from a clinic that have two cats that are anorexic, lethargic, and may have been vomiting. There is a third cat in the home that had the same symptoms previously but have since resolved. The owner had the product out 3 to 4 days ago, but no exposure was witnessed. 7.15.2013 Callback to the original caller for follow up information. One of the cats developed pancreatitis, and the other cat was fine within a few days.
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 Interviews. 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 insidious development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and 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, such illness would be unexpected and is not consistent with the toxicological profile of this product.
