Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-5729
2. Registrant Information.
Registrant Reference Number: 1473545
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.
30-SEP-14
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
25-SEP-14
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. 18449
PMRA Submission No.
EPA Registration No.
Product Name: Raid Liquid Ant Killer - Canada
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
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?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
DSH
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
10.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
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?
Unknown
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
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
9/30/2014 Caller states that her cat ate a mouse on 9/26/2014 that may have eaten the product. Yesterday the cat became lethargic. 10/3/2014 Attempted call back to the original caller. A message was left requesting follow up information.
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.
9/30/2014 Caller states that her cat ate a mouse on 9/26/2014 that may have eaten the product. Yesterday the cat became lethargic.