Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-1367

2. Registrant Information.

Registrant Reference Number: 2881686

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.

16-FEB-21

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

16-JUL-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. 33093      PMRA Submission No.       EPA Registration No.

Product Name: OFF! Mosquito Coils (starter)

• Active Ingredient(s)
  • METOFLUTHRIN
    • Guarantee/concentration .02 %

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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.

Other

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Conjunctivitis
  • Symptom - Other
  • Specify - Mark on the white part of his eye

• General
  • Symptom - Edema
  • Specify - eye lid

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)

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

Other

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.

Unknown

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.)

2/16/2021 Caller and her husband were at a friend's house in July or August 2020. The product was burning on the patio, and he was sitting fairly close to the product. The next day, his left eye began having symptoms. His left eye and eyelid started looking like he had pink eye. It was very red, but that has gone down over an unspecified amount of time. The eye lid looks swollen. He has been to an eye specialist a couple of times. The doctors have given him different eye drops and pills. None of the doctors or specialists have been able to determine what is happening. The swelling is better that what it was, but is still not resolved. Caller can see a mark on the white part of husband's eye. She isn't sure if it was there before.

To be determined by Registrant

14. Severity classification.

Moderate

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.