Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4492

2. Registrant Information.

Registrant Reference Number: 1648407

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.

16-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

15-JUL-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. 25303      PMRA Submission No.       EPA Registration No.

Product Name: Raid Max Wasp & Hornet Foam Bug Killer 500g - Canada

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

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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. - Out Home / Rés - à l'ext.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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Decreased vision

• General
  • Symptom - Weakness

• Skin
  • Symptom - Tingling skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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)

Application

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

7/16/2015 Caller was spraying the product yesterday when the nozzle fell off. Caller taped the nozzle back into place, and continued spraying. The product leaked out around the nozzle and onto her hands and arms. Caller continued to spray, and noticed that her arms felt like they were tingling. The tingling subsided 10 minutes after she washed her hands and arms. Today caller feels weak, lightheaded, and states that her vision was dark (similar to coming inside on a bright day) for about 15 minutes where she was barely able to see. Caller has been drinking water, and states that her blood pressure and heart rate are both normal. Follow-up was attempted on 7/24/2015 A, however, there was no answer, and no way to leave a message.

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. Product has a very wide margin of safety, such that even direct skin contact with the liquid pesticide would not be expected to produce such systemic symptoms as lightheadedness and weakness. Dermal contact may be associated with transient paresthesia.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Pressurized product /Prod. sous pression

2. Did packaging failure occur during?

Use of Product

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.

7/16/2015 Caller was spraying the product yesterday when the nozzle fell off. Caller taped the nozzle back into place, and continued spraying. The product leaked out around the nozzle and onto her hands and arms. Caller continued to spray, and noticed that her arms felt like they were tingling. The tingling subsided 10 minutes after she washed her hands and arms. Today caller feels weak, lightheaded, and states that her vision was dark (similar to coming inside on a bright day) for about 15 minutes where she was barely able to see. Caller has been drinking water, and states that her blood pressure and heart rate are both normal. Follow-up was attempted on 7/24/2015 A, however, there was no answer, and no way to leave a message.

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. Product has a very wide margin of safety, such that even direct skin contact with the liquid pesticide would not be expected to produce such systemic symptoms as lightheadedness and weakness. Dermal contact may be associated with transient paresthesia.