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Sécurité des produits de consommation

Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2013-1305

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 1032866

Nom du titulaire (nom légal complet, aucune abbréviation): S.C. Johnson and Son, Limited

Adresse: 1 Webster Street

Ville: Brantford

État: ON

Pays: Canada

Code postal /Zip: N3T 5R1

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

Défaillance de l'emballage

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

29-AUG-12

5. Lieu de l'incident.

Pays: CANADA

État: BRITISH COLUMBIA

6. Date de la première observation de l'incident.

25-JUL-12

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

ARLA No d'homologation 27324      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: OFF! familycare Spray Insect Repellent Summer Splash 175mL - Canada

  • Matière active
    • DEET (N,N-DIETHYL-M-TOLUAMIDE) PLUS RELATED ACTIVE TOLUAMIDES (ORTHO & PARA ISOMERS)

7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Personal use / Usage personnel

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Non

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: >19 <=64 yrs / >19 <=64 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

  • Systèmes nerveux et musculaire
    • Symptôme - Autre
    • Specify - Tactile sensory abnormality
  • Peau
    • Symptôme - Brûlures (au 2ème ou 3ème degré)
    • Symptôme - Fourmillement

4. Quelle a été la durée des symptômes?

>1 mo and <= 2mos / >1 mois et < = 2mois

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Oui

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Application

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Peau

11.Durée de l'exposition?

<=15 min / <=15 min

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

<=30 min / <=30 min

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

August 29, 2012 Consumer called to report an incident that occurred at his cabin on July 20th. When it was pressed down, it would not pop back up. Consumer states that the pump spray device on this bottle had broken by some unknown means previously. The caller had not actually purchased the product but had borrowed it from his brother. The brother did not recall how the pump spray had become broken. Because the pump spray was not working, a family member had unscrewed the enclosure so that it may be poured into the caller's hands in order to spread it around the skin on his body. While the product was being poured into his hands, it trickled down between his fingers and landed near a campfire which was approximately 1.5 ft away. The campfire then flared up and caused the caller's hands top catch fire. Caller immediately jumped into a nearby lake in order to put his hands in the lake water. He was then transported to a local hospital. At hospital he was diagnosed with 2nd and 3rd degree burns. He required aggressive burn care that included surgical debridement of the burn wounds in the ER. He was not admitted to the hospital but he required aggressive outpatient care for an extended period of time. His hands were bandaged for 2.5 weeks and required regular applications of antibiotic. He consulted with a plastic surgeon and it was determined that he will not require skin graphs. He has lost the ability to sense temperature changes with his hands and he has a persistent tingling sensation. The burn doctor had indicated these are normal symptoms following serious burns and that they should gradually dissipate. He was told that his hands appear to be healing nicely and no further complications are expected.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

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.

Sous-formulaire VI : Défaillance de l'emballage

1. Type d'emballage défaillant?

Spray Bottle / Flacon pulvérisateur

2. La défaillance de l'emballage est apparue pendant?

Autre

préciser The consumer did not know how the pump spray device broke.

3. La défaillance de l'emballage a donné lieu à :

une blessure potentielle

une exposition potentielle

4.Décrire pourquoi l'emballage a été défaillant et dans quelles circonstances, décrire notamment la blessure ou l'exposition potentielle.

August 29, 2012Consumer called to report an incident that occurred at his cabin on July 20th. When it was pressed down, it would not pop back up. Consumer states that the pump spray device on this bottle had broken by some unknown means previously. The caller had not actually purchased the product but had borrowed it from his brother. The brother did not recall how the pump spray had become broken. Because the pump spray was not working, a family member had unscrewed the enclosure so that it may be poured into the caller's hands in order to spread it around the skin on his body. While the product was being poured into his hands, it trickled down between his fingers and landed near a campfire which was approximately 1.5 ft away. The campfire then flared up and caused the caller's hands top catch fire. Caller immediately jumped into a nearby lake in order to put his hands in the lake water. He was then transported to a local hospital. At hospital he was diagnosed with 2nd and 3rd degree burns. He required aggressive burn care that included surgical debridement of the burn wounds in the ER. He was not admitted to the hospital but he required aggressive outpatient care for an extended period of time. His hands were bandaged for 2.5 weeks and required regular applications of antibiotic. He consulted with a plastic surgeon and it was determined that he will not require skin graphs. He has lost the ability to sense temperature changes with his hands and he has a persistent tingling sensation. The burn doctor had indicated these are normal symptoms following serious burns and that they should gradually dissipate. He was told that his hands appear to be healing nicely and no further complications are expected.

À l'usage du titulaire seulement

5. Donner des renseignements additionnels ici.

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.