Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6531

2. Registrant Information.

Registrant Reference Number: 1571179

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.

15-MAR-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

14-MAR-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. 29831      PMRA Submission No.       EPA Registration No.

Product Name: Raid Max Flying Insect Killer 2 500g - Canada

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • PIPERONYL BUTOXIDE

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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?

No

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Coughing
  • Symptom - Runny nose

• Skin
  • Symptom - Dry skin

• Respiratory System
  • Symptom - Other
  • Specify - dry nose

• Gastrointestinal System
  • Symptom - Other
  • Specify - dry lips

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)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

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.)

3/15/2015 Caller reports that she sprayed the product around her home yesterday morning, and then left the house for eight hours. Caller reports that she developed a headache soon after coming home, but that her headache dissipated when she got fresh air. Caller reports that she has a headache again today, and her nose is running. Caller reports that the skin on her nose and her lips are dry. Caller reports that she was spraying the product directly on insects in an attempt to kill them, and did spray the product again today. Caller reports that the product has a strong odor and causes her to cough. Caller does not describe a specific oral, dermal, ocular, or respiratory exposure to the product. Caller also reports that she has used her asthma inhaler, but does not have any auditory wheezing or respiratory difficulty. 3/24/2015 Attempted call back to the original caller for follow up information. The answering party states this is the wrong number.

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.