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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2217
2. Registrant Information.
Registrant Reference Number: 1861025
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.
05-FEB-085. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
08-JAN-08Product 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)PMRA Registration No. 26923 PMRA Submission No. EPA Registration No.
Product Name: Wilson Ant Killer Dust
- Active Ingredient(s)
- CARBARYL
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: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Diarrhea
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
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)
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.
Oral
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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 daughter had got into some product which had been coated on her hands and then proceeded to put her hands in her mouth. Mom has the child in the tub right know and is cleaning her up. Caller wants to make sure that she is going to be ok. The operator who fielded the call advised the caller to watch for symptoms that may become visible such as vomiting, diarrhea, or excessive drooling, and if so seek medical attention. In the mean time 1) Dilute with 2-6oz of fluids for children and 6-8 oz for adults 2) If you experience difficulty swallowing, mouth, stomach pain or vomiting, seek medical attention 3) Wash exposed skin well with soap and water 4) Pat dry. An hour later the operator called back the mother of the exposed child to enquire into how the child is doing? The mother informed the operator that the child had a episode of diarrhea and was taken in to the hospital, however is doing fine. Several hour later it was learnt from a doctor at the local urgent care that the child was experiencing a touch of the flu and the symptoms of diarrhea were a result of the flu.
To be determined by Registrant
14. Severity classification.
Minor
