Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-6767

2. Registrant Information.

Registrant Reference Number: 3686573

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.

11-AUG-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)

---

PMRA Registration No. 31897      PMRA Submission No.       EPA Registration No.

Product Name: RAID Bed Bug Killer, 350g [Canada]

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

---

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

---

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?

No

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

• Eye
  • Symptom - Other
  • Specify - Stye

• General
  • Symptom - Malaise

• Nervous and Muscular Systems
  • Symptom - Headache

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)

Application

Contact with treated area

What was the activity? Returning to the area where she applies the products in her apartment.

Poisoning from ingestion of the pesticide

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.

Oral

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.)

8/11/2023 Consumer reporting that she experienced headache, malaise and a stye on her eyelid when using the products. She lives in a small apartment and has been having issues with house flies. She is unable to swat the flies due to weakness in her arms so she has been using both products frequently in her apartment each day since she purchased them. She began using the RAID Bed Bug Killer on approximately 08/02/23 and using the RAID Home Insect Killer on approximately 08/08/23. She states that she will apply the products directly to the insects, but they are not dying and she still has flies in her apartment. She states she has to use the products several times a day because they are not effective which has been causing her to experience malaise and headaches. She also mentions that she has been experiencing styes on her eyelids from having to use the products so much. She states that she has been keeping the windows open since she has been using the products often. She states that she does leave the area once she sprays the product. She clarifies that when she is away from the products or where they were applied, her symptoms resolve. Her symptoms return once she is back near where the products were applied. 8/11/2023 Text message from consumer: I had two raid products , one I bought out of desperation because I couldnat find the regular home one. I have ingested a ridiculous amount of product and these flies are not dead. I trapped one fly in a cup on a napkin soaked in raid the next day it was not dead, still flying in the cup I lifted the cup to spray A LOT more and it still took a long time to die a| which Iam not even sure it is dead because itas not on its back. 8/14/2023 Call back to the consumer. Call was not answered and went to voicemail. Left a detailed message with the reason for the call, the phone number to call back, and the case number. Advised that they may call us back anytime, 24 hours a day, 7 days a week. No further information is available.

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.