Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-5583

2. Registrant Information.

Registrant Reference Number: 2704985

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.

29-JUN-20

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

20-JUN-20

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. 30744      PMRA Submission No.       EPA Registration No.

Product Name: RAID Outdoor Ant Nest Destroyer 2, 400g [Canada]

• Active Ingredient(s)
  • D-PHENOTHRIN
  • TETRAMETHRIN

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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

• Skin
  • Symptom - Blister

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.

Yes

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.

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

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.)

6/29/2020 Caller got the product on her skin approximately 9 days ago during application. She was wearing gloves, but thinks there may have been a hole in them. While using the product, it leaked from the nozzle and ran down her gloved hand. After she finished the application, she removed her gloves and washed her hands for one minute. The next day, caller started developing blisters on her hand between her fingers and on top of her fingers. There are lots of little blisters between her fingers, and two blisters on the top of her finger that have merged into one large blister. She continues developing blisters today. She denies any open skin. No therapies have been performed at home. 7/1/2020 Attempted call back to the original caller. A message was left requesting follow up information. Caller is returning the previous message. She went to her doctor yesterday. The doctor did not have answers, and sent a culture to the lab. Caller was prescribed a steroid cream for treatment, and advised to use cotton gloves to protect the affected area. 7/8/2020 Call back to the original caller for follow up. She has not heard about the test results yet. She finished the prescription yesterday. The blisters are much better. The large blister was broken by her doctor, and that has not completely healed yet. 7/15/2020 Call back from the original caller to update on the test results. She was tested for chicken pox and herpes, and both tests were negative.

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.