Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2024-6382

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 3984244

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

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

19-AUG-24

5. Lieu de l'incident.

Pays: CANADA

État: NEW BRUNSWICK

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

Inconnu

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)

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ARLA No d'homologation 29776      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: RAID Wasp & Hornet Bug Killer 7, 400g [Canada]

• Matière active
  • D-PHENOTHRIN
  • TETRAMETHRIN

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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: Res. - Out Home / Rés - à l'ext.maison

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?

Inconnu

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: Unknown / Inconnu

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

Système

• Système cardiovasculaire
  • Symptôme - Douleur à la poitrine

• Oeil
  • Symptôme - Irritation de l'oeil

• Système gastro-intestinal
  • Symptôme - Brûlure à la bouche
  • Symptôme - Diarrhée
  • Symptôme - Nausée

• Systèmes nerveux et musculaire
  • Symptôme - Étourdissement
  • Symptôme - Mal de tête
  • Symptôme - Faiblesse musculaire

• Système respiratoire
  • Symptôme - Nez irrité
  • Symptôme - Irritation des voies respiratoires

• Peau
  • Symptôme - Érythème
  • Symptôme - Irritation de la peau
  • Symptôme - Rougeurs sur la peau

• General
  • Symptôme - Sensation de faiblesse

• Peau
  • Symptôme - Sensation de brûlures à la peau

• Système gastro-intestinal
  • Symptôme - rritation de la bouche

• Système respiratoire
  • Symptôme - Douleur des voies respiratoires

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Quelle était l'activité? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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.

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

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

Unknown / Inconnu

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.)

8/19/2024 Per Customer Resource Center staff, the product was sprayed around the caller's home, and he indicated that it had a strong odor. It is not clear if he has had symptoms. 8/19/2024 Called back to speak to the initial caller. He indicates that he sprayed the product onto a hornet's nest on his daughter's house. The product dripped down the wall and got into a hole where cables go into the home. The initial caller indicates that none of his daughter's family members are experiencing any symptoms, but every time he goes over to the home, he develops a headache and becomes flushed. He admits that he does have allergies but does not know what is causing his symptoms. He did spray the walls down several days after the product was sprayed. 8/20/2024 Comments from consumer email consumer had also sent: I recently use Raid Hornet and Wasp killer. I have concerns that I may have released some of the spray into my home. I was spraying the Rain on the exterior wall. I did not notice a small hole in the wall, where cables went into the home in the area I sprayed. A day later I could smell the Pesticide odor in my basement. No further information is available.9/16/2024 Caller states he continues to have chest pain, weakness, feeling faint, nausea, skin burning, headache and diarrhea on and off since product use. The caller reported he continues to smell the product odor in his daughteras home. He can smell the product on his clothing when he leaves his daughteras home. He believes he carried the odor into his home on his clothing. Ever since he used the product, he has experienced chest pain, feeling weak, feeling faint, nausea, skin burning, headache and diarrhea. The caller did not report losing consciousness. He expressed he felt as if he would faint. The caller did not report having symptoms at time of call. The symptoms occur even when he is at his own home. The symptoms come and go sporadically. The caller became concerned his symptoms were cardiac related. He saw his primary care provider on approximately 09/12/2024.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Narrative continued: The primary care provider did not do any type of diagnostic testing or prescribe any treatment. The caller stated his heart was fine. His doctor thought symptoms could be related to the product. The doctor suggested he could have sensitivity to product that caused an allergy flare up. His doctor advised symptoms should resolve on their own. The patient was told if symptoms worsen or persist to return for follow-up. The patient continues to have symptoms on and off. The caller used the product approximately August 2024. He sprayed a wasp nest on the outside vinyl siding of the home. He noted some product ran down the wall during application. There is a hole in the vinyl siding where wires go into the home. He is worried the product entered the home by going into the hole with the wires. The caller asked if propellant could be causing a chemical reaction with vinyl siding. He reported a strong odor in the basement of the home since the day of product application. He denies using the product in the basement. He only sprayed it outside on the vinyl siding. He washed the siding off with soap and water on approximately 3 days later. The caller reported he is very concerned about his grandchildren that live in the home. He asked if there is additional information on how to remove the product from home and clothing. The other family members including his grandchildren have remained asymptomatic and deny smelling the product odor. He reported the odor in the basement smells like this product. The caller denies using any other chemicals or products in the home. 9/18/2024 Attempted callback and spoke with caller. He states he is still having the same symptoms. The smell is not as strong, but he can now smell it in his own home and in his car. He now has irritation of eyes nose and mouth. Nausea persists. He is not being treated for any of his symptoms. He is using a puffer for his chest pain, and states his doctor confirmed it is respiratory pain. He was diagnosed with irritation of the airways. 10/17/2024 Attempted callback and spoke with caller. He states he still has health issues related to the product including respiratory issues and sensitivities related to the product. His doctor put him on meds including a puffer and told him it would take time. He still cannot go to his daughter's house. His doctor said this was related to the product. 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.