Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6531

2. Registrant Information.

Registrant Reference Number: 3318458

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.

05-JUL-22

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

01-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)

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PMRA Registration No. 30097      PMRA Submission No.       EPA Registration No.

Product Name: OFF! Deep Woods Insect Repellent Dry, 113g [Canada]

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

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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: 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.

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

• Skin
  • Symptom - Other
  • Specify - Abrasion
  • Symptom - Other
  • Specify - Skin adhesion
  • Symptom - Discolouration
  • Symptom - Lesion
  • Specify - Laceration
  • Symptom - Bleeding

• General
  • Symptom - Pain

• Skin
  • Symptom - Peeling skin

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?

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.

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.)

7/5/2022 Caller applied the product to herself 4 days ago before going outside. She was wearing shorts and a t-shirt, and sprayed uncovered skin areas with the product. A couple of minutes after application, she sat down on a wooden bar stool to put on her shoes. She sat there for what she estimates as 5 minutes or so before standing up. When she stood up she found that the backs of her thighs were stuck to the stool, and it peeled some of the skin off of her leg and some of the finish off of the stool. The skin had some black marks of finish and also some open areas that were bleeding. She washed the area with soap and water, and applied Polysporin to the open areas. The area was pretty sore for a couple of days, but is less sore today and no signs of infection. 7/8/2022 Attempted call back to the original caller for follow up. There was no answer and no way to leave a message.

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.