Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6519

2. Registrant Information.

Registrant Reference Number: 020791778A

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

Packaging Failure

4. Date registrant was first informed of the incident.

22-AUG-22

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

Unknown

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. 30746      PMRA Submission No.       EPA Registration No.

Product Name: RAID MAX WASP & HORNET FOAM BUG KILLER 2

• Active Ingredient(s)
  • D-PHENOTHRIN
  • TETRAMETHRIN

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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).

Customer used it on a hornet nest in a pear tree. After shaking the can for quite some time, the user stood about a meter from the nest and sprayed it into the hole of the nest. About 25 cm of foam came out of the it instead of the 1 to 3 m stated on the label.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Pain
  • Symptom - Other
  • Specify - Hornet sting

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

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

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

While husband was applying product to nest the data subject was standing nearby and was stung by a hornet 3 times.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Pressurized product /Prod. sous pression

2. Did packaging failure occur during?

Use of Product

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Customer reported that the bottle started sputtering and working erratically when used. As the hornets tried getting out of the next one hornet stung a bystander.

For Registrant use only

5. Provide supplemental information here.

No actual exposure was reported by the consumer. The information contained in this report is based on self-reported statements provided to the registrant during e-mail communications and/or 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.