Abstract: At approximately 9:30 a.m. on Friday, May 3, 1991, housekeeping was called to the dirty instrument room in the hospital's operating room area to clean up a small (9 in. by 12 in.) formalin spill. While Employee #1 was using a mop to clean up the liquid, her nose and throat became irritated by the formalin vapors. Approximately one hour later, Employee #1 started to feel dizzy and intoxicated. She was taken to the emergency room, and then sent home. She had a headache and hangover-like symptoms for the next 2 days. Employee #1 had not had proper hazard communication training or personal protective equipment for the situation. Also, the clean-up procedures were incorrect for a substance containing formaldehyde.