Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-3705

2. Registrant Information.

Registrant Reference Number: 3330598

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.

18-JUL-22

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

14-JUL-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)

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 4822-572

Product Name: OFF! Deep Woods Dry Insect Repellent VIII, 4oz

• Active Ingredient(s)
  • DEET (N,N-DIETHYL-M-TOLUAMIDE) PLUS RELATED ACTIVE TOLUAMIDES (ORTHO & PARA ISOMERS)
    • Unknown

---

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: Personal use / Usage personnel

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: Female

Age: <=1 yr / < = 1 an

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Blister
  • Symptom - Peeling skin
  • Symptom - Burns (superficial)

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?

Yes

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)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

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

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.)

7/18/2022 Caller states she applied the product to her daughter's legs and feet on 7/14/2022. They were outside for about 6 hours, and then as soon as they got into the house she gave her daughter a bath and the water was not hot. After the bath, her daughter had a few blisters. They took her to the emergency room on 7/14/2022. Caller is asking if the hospital washed her daughter's legs and feet with warm to hot water if this would cause her daughter's symptoms? They brought her to another hospital, and before arriving her daughter's symptoms worsened. She had increased blisters and her feet were peeling. Her daughter was admitted to the hospital and is being treated with burn cream. 7/22/2022 Call back to the original caller for follow up. Her daughter is still in the hospital. She had skin graft surgery on her lower legs, front and back, and the tops and bottoms of her feet. Her diagnosis was a chemical/scald burn. They told her this was from the product and then using water on it.

To be determined by Registrant

14. Severity classification.

Major

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.