Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-5562

2. Registrant Information.

Registrant Reference Number: 3716108

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.

13-SEP-23

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

09-SEP-23

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: OFF! Deep Woods - non-specific

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

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7. b) Type of formulation.

Liquid

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Edema
  • Symptom - Other
  • Specify - Rhinovirus

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Specify - Unable to walk
  • Symptom - Shakiness

• Respiratory System
  • Symptom - Shortness of breath
  • Symptom - Difficulty Breathing

• Cardiovascular System
  • Symptom - Bradycardia

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?

Yes

6. b) For how long?

3

Day(s) / Jour(s)

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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.)

9/13/2023 Caller is not at home but knows the product is Off Deep Woods. Caller reporting for her son who developed a swollen bottom lip, difficult breathing, shaking, inability to walk and low pulse rate after exposure to the product. Caller states her son sprayed the product on his face, arms, and legs about 9pm on 09/09/2023. Around 1030pm on 09/09/2023 her son was sucking on his bottom lip and his bottom lip swelled up, difficulty breathing, shaking and he was unable to walk. Her son stated he showered before the symptoms started but she is not too sure her did. She brought him into Urgent Care on 09/10/2023 and was sent to the Emergency Room. In the Emergency Room they did an echocardiogram, which was normal. A virus panel was completed and came back showing he had Rhinovirus. His pulse rate was running about 50. He was administered intravenous fluids, but not other medications, and admitted after 4 hours. As of the night of 09/12/2023 his symptoms are improving. They are planning on a computed tomomgraphy scan of his head 09/14/2023. She states she told the doctors that he used the product and his symptoms started after, but she stated the doctors laughed it off. She is wondering if the product could be causing his symptoms. 9/15/2023 Attempted callback. No answer. Full mailbox. Unable to leave message. 9/18/2023 Attempted callback and spoke with caller. Her son is well and was discharged on 9/13/23, 3 days in hospital. No further tests were done. No definitive diagnosis was given, the doctors did not agree it was a possible allergic reaction, saying it could be a possible underlying virus. Caller still has the product at home and will keep it for us. She okayed another callback for this purpose. She wants to know if reactions are common. Are there dangerous ingredients? 9/20/2023 Attempted callback: The mailbox is full. Unable to leave a message. 9/21/2023 Attempted callback: Left a detailed message requesting a callback. Case and callback numbers provided.

To be determined by Registrant

14. Severity classification.

Major

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.