Abstract: On July 29, 1994, Employee #1 and coworkers in a neonatal step-down unit were performing normal work tasks which entailed personal care of newborn babies. An odor was detected near bedspaces 8, 9, and 10. Engineering services was contacted by the employer to investigate the odor. A Hewlett-Packard 78801-A infant monitor was removed from the work area. Later that day, Employee #1 went to the employer's emergency room and was released at 11:30 p.m. She suffered nausea and dizziness from a probable inhalation injury. Employee #1 was later diagnosed with a neurological disorder of unknown etiology. The causal factor of the illness has not yet been determined.