Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6543

2. Registrant Information.

Registrant Reference Number: 3363963

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.

24-AUG-22

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

23-AUG-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. 32308      PMRA Submission No.       EPA Registration No. 4822-605

Product Name: OFF! Mosquito Lamp (lamp, diffuser & candle)

• Active Ingredient(s)
  • METOFLUTHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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)

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

Other

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.)

8/24/2022 Caller was using the product around 17 hours ago. As the product was getting to the end of its use it started to smoke and caught fire. The caller stated that her shed also filled with smoke. The caller is now experiencing a migraine headache that started about 30 minutes after the incident. Caller stayed home from work today, is getting fresh air, and did take Advil for the migraine. Caller has a history of chronic bronchitis. 8/25/2022 Call back to the original caller for follow up. The headache has resolved, and she feels much better and was able to go to work today.

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.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Other / Autre

specify Lamp, diffuser and candle

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.

8/24/2022 Caller was using the product around 17 hours ago. As the product was getting to the end of its use it started to smoke and caught fire. The caller stated that her shed also filled with smoke. The caller is now experiencing a migraine headache that started about 30 minutes after the incident. Caller stayed home from work today, is getting fresh air, and did take Advil for the migraine. Caller has a history of chronic bronchitis. 8/25/2022 Call back to the original caller for follow up. The headache has resolved, and she feels much better and was able to go to work today.

For Registrant use only

5. 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.