Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1299

2. Registrant Information.

Registrant Reference Number: 1026955

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

Address: 399 Interpace Parkway

City: Parsippany

Prov / State: NJ

Country: USA

Postal Code: 07054

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

Human

4. Date registrant was first informed of the incident.

18-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

18-AUG-12

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. 30284      PMRA Submission No.       EPA Registration No.

Product Name: LYSOL Fabric Mist Blossoms Spring Time 9/800ML

• Active Ingredient(s)
  • DIDECYL DIMETHYL AMMONIUM CHLORIDE

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Red eye
  • Symptom - Irritated eye

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)

Other

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.

Eye

11. What was the length of exposure?

<=15 min / <=15 min

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.)

August 18, 2012 Caller is a medical student working at an outpatient clinic. He child was brought into their clinic with a history of spraying some kind of household spray in his eyes. The exposure history is vague. They state that the Lysol spray may have been involved, however, they also suspect that two sprays may have been involved. The child has red irritated eyes. The clinic has not applied any specific treatments to this child. The parents had rinsed the eyes at home.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.