Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-5594

2. Registrant Information.

Registrant Reference Number: 2753719

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.

31-AUG-20

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

24-AUG-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. 32966      PMRA Submission No.       EPA Registration No.

Product Name: RAID MAX Bed Bug Killer, 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: 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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Edema

• Skin
  • Symptom - Erythema
  • Symptom - Hives
  • Symptom - Itchy skin

4. How long did the symptoms last?

Unknown / Inconnu

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

8/31/2020 Caller applied the product one week ago in his bedroom and his minivan. Caller also believes his work truck has residue from when he transported the mattress to the dump, which he says was bagged in plastic. Caller developed itching and hives approximately 4 hours after use of the product. The hives progressed from the top of his head down to his belly button. He also experienced redness and swelling. Caller went to the emergency room on 8/25/2020, and was given oral Prednisone to take for 5 days. He is also taking Benadryl every 4 to 6 hours. Caller had to miss 3 days of work due to his symptoms. His wife used dish soap to wash the product from surfaces and seems to have gotten rid of everything. His work clothes have been laundered multiple times, however he breaks out in new hives and itching every time he puts on his work clothes. 9/3/2020 Call back to the original caller. He is still getting new hives every day despite taking the steroid and allergy medications. 9/8/2020 Call back to the original caller. He is trying a third and fourth allergy medication. He is not home and does not know the names of the medications. He is waiting for a call back from a Dermatologist. 9/15/2020 Call back to the original caller. The symptoms are still the same. He has changed laundry products. He now states his home was sprayed by a professional bug company who used products with the same ingredients.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The skin reaction reported in this case may have multiple potential and targeted allergy testing would be required before concluding that this product may be the causative agent. Secondly, the history lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this product occurred, such prolonged symptoms would not be expected.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.