Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2222

2. Registrant Information.

Registrant Reference Number: 3535027

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.

02-MAR-23

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. 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.

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 - Other
  • Specify - Spitting up white material
  • Symptom - Irritated throat

• Respiratory System
  • Symptom - Shortness of breath
  • Symptom - Difficulty Breathing
  • Symptom - Sore throat
  • Symptom - Other
  • Specify - Throat feels like it has a lump in it

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

Drift from the application site

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

3/2/2023 Caller reports throat irritation, difficulty breathing, and spitting up white material with use. He also asks if this product causes cancer and has concerns over the Pesticide Control Product Act mentioned on the label. He sprayed this product heavily one week ago (on or around 02/23/2023), one time only for suspected bedbugs on his bed. He sprayed around the edges of his bed, the ledges of the bed frame, around the bed and underneath. He had opened the windows as he sprayed, but feels it has a strong odor that he does not like. A few hours later, he developed throat irritation. The next day, he began to experience having to spit and when he does, white material comes out. He still smells the odor of it and is still having the symptoms, which have improved, but not resolved. He has been going outside for fresh air but it does not seem to help. He would like trying to use the product again. 3/3/2023 Attempted call back and spoke with caller. He is better but not back to normal. His throat feels like it has a lump in it and there is a very slight soreness. He is taking zinc, vitamin D and vitamin C to treat his symptoms. He tried to seek an exam but they refused to let him in because they thought he might have COVID. 3/7/2023 Attempted call back and spoke with caller. He is much better. He ate some Quaker oats which helped his throat symptoms improve very quickly. He is at the doctor's office now, waiting to be seen.

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.