Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1960

2. Registrant Information.

Registrant Reference Number: 1935777

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.

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. 17971      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Liquid Sevin Insecticide

• Active Ingredient(s)
  • CARBARYL

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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. - Out Home / Rés - à l'ext.maison

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Nausea

• Respiratory System
  • Symptom - Nasal congestion
  • Symptom - Runny nose
  • Specify - Secretions

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)

Chemical resistant gloves

Respirator

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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 her husband used product last 2 days. He is feeling kind of dizzy and has a lot of congestion and secretions. Caller says he takes medication to lower BP for prostate problem. The caller was advised that symptoms could be related to product and to have her husband take the product into the doctor's with him. Later on during a follow up that day the husband indicated that he did go to the ER today and was evaluated by the ER physician and he was told he is `all right ` He had worn a mask and gloves when administered the pesticide. He wonders if he had inhaled product , felt a little nauseated but had no respiratory problems states he did shower head to toe this am , states the symptoms are resolving. He also indicated that he had similar incidence of this dizziness for over a week now, previous to exposure.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

It is hard to pin point as to what caused the symptoms, however symptoms as a result of exposure to Carbaryl only usually last about 24hrs not a week.