Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4846

2. Registrant Information.

Registrant Reference Number: 1368982

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.

21-APR-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

01-APR-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)

---

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

---

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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Erythema
  • Symptom - Irritated skin

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)

Contact with treated area

Amount of time between application and contact 1

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

4/21/2014 Caller sprayed product over and on her living room carpet about 3 weeks ago. Caller's daughter told her that she walked on the carpet while it was still wet an hour or two later, and wore wet socks all day. That night daughter felt dermal irritation around her toes on both feet. She has been applying lotion and two nights ago applied rubbing alcohol. Daughter has not prior history of allegies or sensitivities.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.