Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-6850
2. Registrant Information.
Registrant Reference Number: 5682876
Registrant Name (Full Legal Name no abbreviations): Sure-Gro IP Inc.
Address: 1900 Minnesota Crt
City: Mississauga
Prov / State: Ontario
Country: Canada
Postal Code: L5N 3C9
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
10-OCT-16
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
08-SEP-16
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. 30535
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Wilsarin Rat and Mouse Killer
- Active Ingredient(s)
- CELLULOSE (FROM POWDERED CORN COBS)
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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
unknown
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
9.9
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
specify ingestion of poisoned mouse
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The caller's cat ingested a mouse that may have eaten some of the product. TOE: 1 week ago. Now, the animal is not eating and lethargic. Vet is suspecting anemia. The animal is usually in GH. O: Anorexia, lethargy A: Acute animal ingestion Wilson Wilsarin Rat and Mouse Killer. R: SX do not appear related to exposure. Caller given case number. Have vet call back with questions/concerns.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.