Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3378

2. Registrant Information.

Registrant Reference Number: 1619300

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

Packaging Failure

4. Date registrant was first informed of the incident.

02-JUN-15

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

01-JUN-15

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. 30598      PMRA Submission No.       EPA Registration No.

Product Name: OFF! Deep Woods Sportsmen Insect Repellent Dry 113g - Canada

• Active Ingredient(s)
  • DEET (N,N-DIETHYL-M-TOLUAMIDE) PLUS RELATED ACTIVE TOLUAMIDES (ORTHO & PARA ISOMERS)

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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 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

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

<=30 min / <=30 min

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Pesticide Spill

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.

Skin

Eye

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

6/2/2015 Caller reports that yesterday the product fell off of a table, and the button became stuck open causing the product to spray continuously. Caller picked up the product to stop the spraying, and was sprayed on his hands, in his eyes, and he inhaled a small amount. Caller immediately felt tingling in his eyes, so he rinsed his eyes and washed his face and hands. The tingling subsided after a minute or two. 6/3/2015 Attempted call back to the original caller. A message was left requesting follow up information.

To be determined by Registrant

14. Severity classification.

Minor

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.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Pressurized product /Prod. sous pression

2. Did packaging failure occur during?

Transportation

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

6/2/2015 Caller reports that yesterday the product fell off of a table, and the button became stuck open causing the product to spray continuously. Caller picked up the product to stop the spraying, and was sprayed on his hands, in his eyes, and he inhaled a small amount. Caller immediately felt tingling in his eyes, so he rinsed his eyes and washed his face and hands. The tingling subsided after a minute or two. 6/3/2015 Attempted call back to the original caller. A message was left requesting follow up information.

For Registrant use only

5. 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.