Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2401

2. Registrant Information.

Registrant Reference Number: 1343301

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.

04-MAR-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

28-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. 30284      PMRA Submission No.       EPA Registration No.

Product Name: LYSOL Fabric Mist Crisp Linen 9/800ML

• Active Ingredient(s)
  • DIDECYL DIMETHYL AMMONIUM CHLORIDE

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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

• Cardiovascular System
  • Symptom - Chest tightness

• Respiratory System
  • Symptom - Respiratory irritation
  • Symptom - Shortness of breath

• Skin
  • Symptom - Erythema
  • Symptom - Hives
  • Symptom - Irritated skin
  • Symptom - Itchy skin
  • Symptom - Rash
  • Symptom - Burning skin
  • Symptom - Tingling skin
  • Symptom - Cyanosis

4. How long did the symptoms last?

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

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

Yes

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?

<=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.)

3/4/2014 Caller sprayed the product on furniture in the living room on 2/28/2014. About 10 minutes later caller developed chest tightness, dermal irritation, skin felt hot and burning, hives, redness, and cyanosis on her fingers and lips. Caller was treated in the emergency room, but is unsure of what treatments were performed. Caller abruptly disconnected. Attempted callback to consumer, and left a message requesting follow up. 3/5/2014 Callback attempted to the original caller. A message was left requesting follow up information. 3/12/2014 Callback attempted to the original caller. A message was left requesting follow up information. 3/13/2014 Callback attempted to the original caller for follow up information. Caller was diagnosed with an allergic reaction in the emergency room. She was kept in the emergency room for about 8 hours. Signs had slightly improved by the time she was discharged, though some bumps, itching, and redness remained. Staff attempted over 30 times to start an intravenous line, and caller still has some bruising from this.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.