Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4847

2. Registrant Information.

Registrant Reference Number: 1340545

Registrant Name (Full Legal Name no abbreviations): Reckitt Benckiser (Canada) Inc.

Address: 1680 Tech Ave Unit #2

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L4W 5S9

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

27-FEB-14

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

13-FEB-14

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. 28059      PMRA Submission No.       EPA Registration No.

Product Name: Lysol Brand Disinfectant Continuous Action Toilet Bowl Cleaner

• Active Ingredient(s)
  • 1,3-DICHLORO-5,5-DIMETHYLHYDANTOIN
  • 1,3-DICHLORO-5-ETHYL-5 METHYLHYDANTOIN

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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?

Yes

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

• Gastrointestinal System
  • Symptom - Nausea

• 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.

Unknown

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

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.

Respiratory

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

2/27/2014 Caller began using the product on Feb. 13. Caller started having headaches when she used the bathroom where product is located. Caller currently has a headache and nausea. Caller has taken analgesic for headaches prior to today, but has not taken anything for this headache. Caller is not able to describe how it is possible for her to be exposed to product other than for her to by using the toilet on a daily basis.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.