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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0002

2. Registrant Information.

Registrant Reference Number: 3105889

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: LOUISIANA

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 4822-229

Product Name: RAID Flea Killer Plus Fogger, 3 x 5fl oz

  • Active Ingredient(s)
      • Unknown
      • Unknown
      • Unknown

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Nausea
    • Symptom - Vomiting
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Gastrointestinal System
    • Symptom - Other
    • Specify - Stomach masses
  • Respiratory System
    • Symptom - Other
    • Specify - Lung masses

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


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


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

11/4/2021 Husband and daughter calling for their wife and mother. The set off one fogger in one room of the house and closed the door on 10/28/2021. They did not leave the home while the product was spraying and did not enter the room for 4 hours. The patient said the odor from the product was making her ill, and she developed a headache, nausea, vomiting, and diarrhea. They got a hotel room for her, and her symptoms persisted. She could not eat or drink without it coming back up. They took her to the emergency room on 11/3/2021 and were there for about 2 hours. They were unable to start an intravenous line in the emergency room. They performed blood work and a computerized tomography scan of her head, but do not have the results yet. No diagnosis was given and no medication was given before she was discharged. Her symptoms are still present. 11/5/2021 Call back for follow up, spoke to patient's daughter. The test results showed a large mass in her stomach and also some masses on her lungs. She is still staying in the hotel room. She is unsure if the doctor thinks the symptoms are related to the product. 11/11/2021 Call back for follow up, spoke to the patient's daughter. The patient is doing better, and she is home now. She is able to keep food and drink down, but only with medication. No diagnosis has been given yet. 11/15/2021 Call back for follow up, spoke to the patient's daughter. The patient is doing ok at this time, and will see the doctor again today. The product was discussed with the doctor, and they said it should not last that long in the house but cannot say if it is related to her symptoms. She has no diagnosis yet, and will see a lung specialist later in the month.

To be determined by Registrant

14. Severity classification.


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.