Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1956

2. Registrant Information.

Registrant Reference Number: 1930129

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: ONTARIO

6. Date incident was first observed.

18-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. 9222      PMRA Submission No.       EPA Registration No.

Product Name: CIL Warfarin Rat and Mouse Bait

• Active Ingredient(s)
  • WARFARIN (PRESENT IN FREE FORM OR AS SODIUM SALT)

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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: Female

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Irritated 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)

Other

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.

Unknown / Inconnu

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 stating that her husband left the product on the counter and some dust from the product spilt on to the counter top. She was trying to pick it up and accidently inhaled some of it. Caller is now having throat irritation. She wants to make sure that she is going to be ok and she would also like to know how to clean it up. Operator who fielded the call recommended to the caller to ventilate the area with fresh air for 30-60 minutes. If symptoms persist, inhale steam from shower and finally If experiencing difficulty in breathing, a persistent cough, or prolonged symptoms occur, seek medical attention. Caller denied call back, outcome unknown

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.