Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6518

2. Registrant Information.

Registrant Reference Number: 1633254

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.

23-JUN-15

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

23-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. 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 III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Boston Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

20.00

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

<=30 min / <=30 min

11. List all symptoms

System

• Cardiovascular System
  • Symptom - Tachycardia

• General
  • Symptom - Pale mucous membrane colour
  • Specify - Abnormal Gum Color

• Gastrointestinal System
  • Symptom - Salivating excessively

• General
  • Symptom - Lethargy

• Respiratory System
  • Symptom - Shortness of breath

• General
  • Symptom - Weakness
  • Specify - very weak

12. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

6/23/2015 Caller is a veterinary technician at a clinic treating a dog. The owner sprayed a wasp/hornet nest yesterday, and while doing so the dog was found ingesting some of the mist or the dying bugs falling from the nest. Today the dog was again ingesting the dying bugs, and 30 minutes ago developed shortness of breath, white mucous, and blue gums. The veterinarian noted that the dog's heart rate was high and the dog was very weak. The dog was put on oxygen and given intravenous fluids. Symptoms have subsided while the dog has been on oxygen. The gums are now noted to be very white.

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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.