Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6507

2. Registrant Information.

Registrant Reference Number: 1672749

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

4. Date registrant was first informed of the incident.

25-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

15-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. 18449      PMRA Submission No.       EPA Registration No.

Product Name: Raid Liquid Ant Killer - Canada

• Active Ingredient(s)
  • BORAX

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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. - 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?

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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

• General
  • Symptom - Fever

• Nervous and Muscular Systems
  • Symptom - Agitation

• Renal System
  • Symptom - Painful urination
  • Symptom - Urinary incontinence

• Respiratory System
  • Symptom - Irritated nose

• Skin
  • Symptom - Itchy skin
  • Symptom - Rash

• Nervous and Muscular Systems
  • Symptom - Restlessness

• Skin
  • Symptom - Burning skin
  • Specify - burning

• Gastrointestinal System
  • Symptom - Nausea

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Other

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

8/25/2015 Caller has been spraying product in his home for years. Two to three weeks ago, a large black ant crawled up his catheter tube in the night and bit him on his penis three times. 10 days later he began to develop sporadic itching rashes which lead to restlessness, nasal irritation, eye irritation, and urinary incontinence. The caller has had previous urinary incontinence which required the use of the catheter. Call from the original caller. He applied Benadryl cream to the affected area, and now the area is burning and he feels nausea. He is going to wash the cream off. 8/27/2015 Attempted call back to the original caller. A message was left requesting follow up information. Caller returned the previous message. He still has a burning sensation on his penis, occasional painful urination, and periods of feverishness. He went to his primary physician yesterday, and was told by the doctor that the ant that bit him did not likely have enough product on it to cause his symptoms. No other diagnosis was given and not specific treatments prescribed.

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. 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. A medical doctor has also ruled out involvement of the pesticide in this patient's illness.