Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1959

2. Registrant Information.

Registrant Reference Number: 1935770

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: UNKNOWN

6. Date incident was first observed.

26-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. 26201      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Jet Foam Wasp and Hornet Killer

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

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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: 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 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

• Eye
  • Symptom - Irritated eye
  • Symptom - Red eye

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Yes

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.

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 says that her husband was spraying product and some of it got in his right eye. He is currently irrigating it. Recommendation was to Irrigate eyes with lukewarm temperature , gentle stream for about 15-20 minutes. Do not hold the eye open and do not use eye drops. If symptoms of pain, redness, irritation or visual disturbances persist, seek immediate opthamalic evaluation . During a follow up call the patient denies pain or visual disturbance, when asked, he says it does feel like there is something in that eye, like foreign body sensation. A day later the caller also indicated that he went into the emergency department and the eye was irrigated again and they applied unspecified drops. Eye is still somewhat read but no visual disturbance.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.