Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-0587

2. Registrant Information.

Registrant Reference Number: 3467170

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-DEC-22

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

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. 31897      PMRA Submission No.       EPA Registration No.

Product Name: RAID Bed Bug Killer, 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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Itchy eye
  • Symptom - Irritated eye

• General
  • Symptom - Swelling
  • Specify - Lip Swelling
  • Symptom - Pain
  • Specify - Rectal Pain

• Respiratory System
  • Symptom - Shortness of breath

• Skin
  • Symptom - Erythema
  • Symptom - Irritated skin
  • Symptom - Tingling skin
  • Symptom - Burning skin
  • Specify - Burning sensation

• Respiratory System
  • Symptom - Difficulty Breathing

• Skin
  • Symptom - Red skin

• Gastrointestinal System
  • Symptom - Other
  • Specify - Pulling senation in bottom area

4. How long did the symptoms last?

Unknown / Inconnu

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)

Contact with treated area

Amount of time between application and contact 1

Day(s) / Jour(s)

What was the activity? Laying on a treated couch.

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?

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.)

12/18/2022 Caller reports that approximately one week prior to call he sprayed his sofa and chair with this product prior to going upstairs to bed with his wife. The following day when his wife laid on the sofa she began to feel a burning sensation on her skin and throughout her body described as being an electrical pulse, difficulty breathing, redness of the skin, eye itching and irritation, and tingling and swelling of her bottom lip. She has been seen by her primary care doctor, and the advice the doctor gave was to get out of the home due to the infestation of bed bugs and cockroaches, which the caller states is from his neighbors in the adjoining home next door. No further testing or treatment was provided by the doctor. The caller claims the doctor stated that the product may have been absorbed into the skin, but he cannot confirm. Caller also spoke with a Canadian poison control center who advised him to ventilate the home and wash all the surfaces treated with the product. Caller states that his wife's signs and symptoms persist at the time of the call. Caller states that he and his wife have tried all of the recommended topical soothers. 12/19/2022 Left a detailed message requesting a call back. Case and call back numbers provided. 12/19/2022 Consumer reports that his wife was seen by her gastrointestinal specialist today (12/19/22), and she is being referred for a colonoscopy as she is experiencing a pulling sensation in her bottom area. She is blaming her symptoms on her husband for spraying this product. The gastrointestinal specialist did not make a statement in regards to the exposure to this product. She may need to see a urologist in the future as well. 12/22/2022 Attempted call back. No answer. Left message with the reason for the call, as well as the case and call back numbers. 12/23/2022 Attempted call back. No answer. Left message with the reason for the call, as well as the case and call back numbers.

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.