Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1954

2. Registrant Information.

Registrant Reference Number: 1919125

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.

12-MAY-08

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

02-APR-08

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)

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PMRA Registration No. 26622      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Indoor/Outdoor Insect Dust

• Active Ingredient(s)
  • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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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).

Caller stated that he was told by the store clerk this was safe to use inside the house. Caller applied it to his carpet on the floors.

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Sore throat
  • Symptom - Coughing

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Irritated throat
  • Specify - tingling in the back of the throat

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 he was told by the store clerk this was safe to use inside the house. Caller applied it to his carpet on the floor. Both himself and his girlfriend are experiencing symptoms. Caller's girlfriend is in good health, no medication. Caller stated that there was no ventilation while using the product. Caller states both him and his girlfriend are experiencing a sore throat, tingling in the back of the throat, coughing and dizziness. Operator who fielded the call advised the caller to ventilate the area as best they can get some fresh air, inhale some steam from a hot steamy shower, sip on some cold fluids. Also he was advised to clean up with wet shop vac, or wet rag. the operator offered a call back and the caller declined. Outcome unknown

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing
  • Symptom - Sore throat

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Irritated throat
  • Specify - tingling in the back of the throat

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 he was told by the store clerk this was safe to use inside the house. Caller applied it to his carpet on the floor. Both himself and his girlfriend are experiencing symptoms. Caller's girlfriend is in good health, no medication. Caller stated that there was no ventilation while using the product. Caller states both him and his girlfriend are experiencing a sore throat, tingling in the back of the throat, coughing and dizziness. Operator who fielded the call advised the caller to ventilate the area as best they can get some fresh air, inhale some steam from a hot steamy shower, sip on some cold fluids. Also he was advised to clean up with wet shop vac, or wet rag. the operator offered a call back and the caller declined. Outcome unknown

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.