Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6506

2. Registrant Information.

Registrant Reference Number: 1672394

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-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

23-AUG-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. 26909      PMRA Submission No.       EPA Registration No.

Product Name: Raid EarthBlends Multi-Bug Killer 350g - Canada

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Toy Poodle

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

8.00

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Bloody stool
  • Symptom - Diarrhea
  • Symptom - Melena
  • Symptom - Vomiting

12. How long did the symptoms last?

Unknown / Inconnu

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?

Unknown

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify Ingested a wasp that died from product use

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

8/24/2015 Caller reports that yesterday caller's dog ate a wasp that had died from the use of the product. Yesterday the dog developed vomiting, anorexia, and diarrhea with blood. The dog had several episodes of vomiting and diarrhea overnight, and was brought to the veterinarian this morning. The dog was given intravenous fluids and other unknown treatments. The dog appears to be improving slightly since returning home. 8/26/2015 Call back to the original caller for follow up information. The dog was brought back to the clinic yesterday morning due to bloody stool that progressed to melena. The dog was put on intravenous fluids and given unknown medications. The dog was brought home last night, and then back to the clinic this morning for intravenous fluids and tests. The veterinarian is performing x-rays and blood work today, and does not yet have a diagnosis.

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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 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.