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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-9109

2. Registrant Information.

Registrant Reference Number: 1846117

Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.

Address: 150 Savannah Oaks Dr.

City: Brantford

Prov / State: Ontario

Country: Canada

Postal Code: N3V 1E7

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

Unknown

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.

PMRA Registration No. 27587      PMRA Submission No.       EPA Registration No.

Product Name: CIL Jet Foam Wasp Hornet Killer

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye
  • Symptom - Swollen eye
  • Symptom - Other
  • Specify - Swollen optic nerve damage

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)

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>6 mos / > 6 mois

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.)

Caller stated that one year ago he was spraying the product and it had hit him in the forehead, got off the latter and washed it off with soapy water. Caller stated that this was on his forehead and in his eyes for about 5 minutes before he could get it off. Caller did go to the eye doctor and they told him that he had irritation / dryness to eyes. Caller stated that his symptoms did not begin to start 6 months after exposure. PMD also stated that he has a swollen optic nerve damage to the right eye. Caller stated that currently his left eye feels like he has something in it. Caller doesn't have the exact name of the product. Symptoms started 6months after exposure eye irritation, left eye irritated, dry eyes, Swollen optic nerve damage. Currently eyes are still dry and now left eye is irritated. The operator who fielded the call informed the caller to continue under PMD care, if the caller finds the product that was used during exposure to call back and information will be given to him.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The third party answering service that fielded the call comprised of registered nurses expressed that these symptoms are not likely related to the product given the actives involved and given the time frame at which this exposure took place over. Also given that the lack of information like the age provided by the caller, it is hard to determine that the exposure to this product may have contributed to the symptoms he is experiencing.