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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2930

2. Registrant Information.

Registrant Reference Number: 809640

Registrant Name (Full Legal Name no abbreviations): DIVERSEY, INC.

Address: 8310 16th Street, P.O. Box 902

City: Sturtevant

Prov / State: WI

Country: USA

Postal Code: 53177-0902

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 15248      PMRA Submission No.       EPA Registration No.

Product Name: SPECTRUM

  • Active Ingredient(s)
    • N-ALKYL (5% C12, 60% C14, 30% C16, 5% C18) DIMETHYL BENZYL AMMONIUM CHLORIDE

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Occupational use of cleaner

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?


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: Male

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

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Conjunctivitis
    • Symptom - Irritated eye

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


11. What was the length of exposure?

<=15 min / <=15 min

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.)

6/26/2011 11:53:01 AM Caller, who is somewhat difficult to understand due to his first language being French, states that he got concentrated product in his eyes last night. He developed eye irritation and rinsed. Today, eyes remain red. He does not wear contacts. Product label bears the words "DANGER" and "CORROSIVE." He was instructed to go to the ER immediately for evaluation and treatment. Follow-up on 7/6/2011 2:31:58 PM Patient went to see a clinic doctor. They rinsed his eyes and prescribed him some eye drops. A few days later he was better. He is now asymptomatic.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.