Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-2011

2. Registrant Information.

Registrant Reference Number: 3177765

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.

22-JAN-22

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

19-JAN-22

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. 31897      PMRA Submission No.       EPA Registration No.

Product Name: RAID Bed Bug Killer, 350g [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: Female

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye
  • Symptom - Tearing

• General
  • Symptom - Other
  • Specify - Swollen lymph nodes

• Skin
  • Symptom - Rash
  • Symptom - Dry skin

• Eye
  • Symptom - Watery eye

4. How long did the symptoms last?

Unknown / Inconnu

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

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.)

1/22/2022 Caller applied the product on 1/19/2022 as directed, and left the house for several hours after spraying. Caller denies any direct exposure to the product. Later that evening on 1/19/2022, she developed an itching rash on one leg. Caller applied Polysporin Itch Cream and some skin lotion, and the itching stopped. Caller has had unusually dry skin, and her eyes have been irritated and watering as well. Caller also had a canker sore in her mouth for a couple of weeks. On 1/21/2022 she noticed a lump on her neck when she rubbed it. She decided to go to the emergency room due to the lump on her neck. She was told that it was swollen lymph glands, which could be due to drainage from the canker sore. The doctor looked at the rash, and suggested it might be from bug bites. They suggested that if she gets further bites, she should call an exterminator. No therapies were performed. 1/26/2022 Call back to the original caller for follow up. Caller does not think the product had anything to do with the rash. Caller did see her doctor. He asked if she had any new bites, and she replied that she did not. He did not have any concerns. The bites have healed.

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.