Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6541

2. Registrant Information.

Registrant Reference Number: 3357419

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.

17-AUG-22

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 32436      PMRA Submission No.       EPA Registration No.

Product Name: RAID Home Insect Killer 2, 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: Male

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting

• General
  • Symptom - Fatigue
  • Symptom - Other
  • Specify - Tightness in neck and shoulders

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Shortness of breath

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?

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

8/17/2022 Caller began using the product in February 2022. He uses the product intermittently and stated that the product does not work to kill flies. He does wear a mask when using the product. He develops shortness of breath, nausea, vomiting, headache, fatigue, and tightness in his neck and shoulders every time he uses the product. He gets fresh air after he uses the product, and his symptoms last 45 minutes before subsiding. He has asthma. The last time he used the product was this morning about 90 minutes ago. He developed the same symptoms today. The symptoms have resolved except for shortness of breath. He did have to go to the hospital 2 times for an asthma attack in the past after using the product. He went to the hospital in May 2022 and then again around 6 weeks ago. The doctor told him the cause of the symptoms was something that had reacted with his asthma. The doctor used an unspecified spray to help him breath. He was on oxygen while at the hospital. He did let the doctor know that he was using the product, and the doctor stated the product could have been related. He went to the emergency room both times, and was discharged after 4 hours. He has a follow up appointment with his doctor in September. The doctor did tell him to stay away from this product. After giving consent to receive a follow up call, caller mentioned taking legal action.

To be determined by Registrant

14. Severity classification.

Moderate

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.