Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2025-3516

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 4033295

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.

25-JUL-25

5. Lieu de l'incident.

Pays: UNITED STATES

État: LOUISIANA

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

Nom du produit: OFF! Deep Woods - non-specific

• Matière active
  • DEET PLUS RELATED ACTIVE TOLUAMIDES
    • Inconnu

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7. b) Type de formulation.

Liquide

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?

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: >19 <=64 yrs / >19 <=64 ans

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

Système

• Systèmes nerveux et musculaire
  • Symptôme - Étourdissement
  • Symptôme - Autre
  • Specify - Epilepsy diagnosis

• General
  • Symptôme - Sensation de faiblesse

• Systèmes nerveux et musculaire
  • Symptôme - Autre
  • Specify - Memory impairment
  • Symptôme - Crise
  • Symptôme - Difficulté de langage

• Système respiratoire
  • Symptôme - Autre
  • Specify - Stopped breathing

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.

Peau

11.Durée de l'exposition?

Unknown / Inconnu

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

>30 min <=2 hrs / >30 min <=2 h

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.)

7/25/2025 Caller reports experiencing tonic-clonic seizure, stopped breathing, lightheaded, dizziness, slurred speech, and memory impairment after use of OFF! Deep Woods - non-specific. He states that as a kid the product was always around for when they went fishing or did things outdoors. In approximately 2003, when he was 16 years old, he was fishing on a lake with his dad. He used the product as directed. One hour later, he experienced a seizure and stopped breathing for about 1.5-2 minutes. He saw a Neurologist and had electroencephalogram, Magnetic resonance imaging, computerized tomography scan, and sleep studies. All results came back normal. He reports that he was advised that he did not have epilepsy and they were unsure why he had the seizure. In 05/2025 he went with his wife and two daughters to their property in another state to go fishing and hiking. On 05/04/2025 his wife and daughters used the product but he did not. When they got back to their camper that night he had ticks on him so he decided that he was going to use the product the next day to keep them away. On 05/05/2025, he was wearing shorts and a t-shirt. He applied the product to exposed skin areas. About 20 minutes later they stopped at an outfitter's store to get snacks and drinks. While in the store he began experiencing lightheaded, dizziness where he felt like he was going to pass out, and slurred speech. He told his wife that he did not feel right. His symptoms worsened while they were checking out at the register. The asked for directions to the nearest hospital. He notes that he does not recall much after this, but his wife obtained the security camera footage from the store and he watched this later. He states that he had a tonic-clonic seizure lasting about 2-2.5 minutes and stopped breathing for about 1.5 minutes. A customer that was a nurse came into the store and assisted him and someone called an ambulance. He reports that he recalls briefly waking up in the ambulance and was given intravenous saline. He saw a neurologist. He notified his provider regarding product use. He states that they wanted to prescribe Keppra for an epilepsy diagnosis to keep seizures away. He does not believe that he has epilepsy as he has only had two seizures in his life that were 22 years apart. He declined the medication due to concerns of side effects. His doctor asked if there were any commonalities between the two seizures. He was unable to identify anything at the time. He is following up with his Neurologist every 6 months. He states that later he realized that he was fishing both times and had used the product. He last used the product on 05/05/2025. He is a business owner/project manager and was unable to work for 2 months. His short-term memory was poor after the event, with a 2-3 minute recall, and this is gradually improving over time.

À être déterminé par le titulaire

14. Classification selon la gravité.

Majeure

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.