Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-5584

2. Registrant Information.

Registrant Reference Number: 2706588

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.

01-JUL-20

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

30-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. 32438      PMRA Submission No.       EPA Registration No.

Product Name: RAID Max Flying Insect Killer 3, 500g [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: Other / Autre

Préciser le type: Garage

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Taste altered

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Coughing

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)

Goggles

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

7/1/2020 Caller sprayed product yesterday one one side of two sets of wicker furniture in their garage while wearing goggles and a mask. She used approximately 2/3 of one can. After applying the product she noticed that her breathing had changed (caller could not be more specific). Last night and this morning she has had a headache. This morning she developed a cough that has since resolved. She also has a bitter tasted in her mouth. The product odor is strong and is coming through the garage. She has left the garage doors and windows open, put towels against the bottom of the door, shut windows in the house, and changed the air filter in her home. She contacted a poison control company who recommended that she take Ephedrine, her husband's Ventolin inhaler, Tylenol, and Loratadine. She took these about an hour ago. Caller is speaking in full sentences without difficulty. 7/2/2020 Attempted call back to the original caller. A message was left requesting follow up information. Call back from the original caller. They washed everything with soap and water and an all purpose cleaner. The furniture is still in the garage with all of the windows and doors open. She is about 50 percent better today. She is continuing to take Loratadine and use the Ventolin inhaler. They are going to leave everything in the garage, and she will call back tomorrow if it hasn't improved.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The reported use of the product is considered misuse per the labeled instructions. Direct exposure could result in temporary respiratory irritation or symptoms like nausea and headache however, direct inhalation exposure was not reported in this case. 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.