Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0298

2. Registrant Information.

Registrant Reference Number: 2942533

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.

30-APR-21

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

30-APR-21

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. 32316      PMRA Submission No.       EPA Registration No.

Product Name: RAID Ant Baits III, 4ct (adhesive back) [Canada]

• Active Ingredient(s)
  • ABAMECTIN

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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: Female

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom -
  • Specify - Soapy taste in the mouth
  • Symptom - Irritated throat
  • Symptom - Nausea
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Numbness

• Gastrointestinal System
  • Symptom - Other
  • Specify - Numb tongue

• Respiratory System
  • Symptom - Sore throat

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

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

Poisoning from ingestion of the pesticide

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.

Skin

Oral

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.)

4/30/2021 Caller opened 4 baits today and put them around her house. Caller has been opening the seal with her thumb nail and then peeling it back with her fingers. Caller said she constantly puts her hands in her mouth on a normal basis, and hasn't washed her hands yet and touched her mouth. She said her tongue is numb and tastes like soap. Caller was nauseous earlier and vomited around lunch time. She washed her hands and is rinsing out her mouth. 5/3/2021 Call back to the original caller for follow up. Caller washed her hands, face, mouth, and lip ring. She changed her clothes and began feeling better later in the evening. But then she had an allergic reaction to an avocado, and developed a sore throat the next day. Caller's daughter also had strep throat the week before, so she believes this may be do to that as well. The numbness and soapy taste in her mouth resolved overnight, but she still has the sore throat. 5/4/2021 Attempted call back to the original caller. A message was left requesting follow up information. 5/5/2021 Caller did not see her doctor. She is prone to strep throat. Her symptoms have resolved.

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.