Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2219
2. Registrant Information.
Registrant Reference Number: 1865156
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.
Domestic Animal
4. Date registrant was first informed of the incident.
05-FEB-08
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
08-JAN-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)
PMRA Registration No. 27492
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Riddex Bloks and Mouse Bait
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Yorkshire Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.25
7. Weight (provide a range if necessary )
1.75
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Abnormal feces colour
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owner's children caught the dog with the block. It is half gone. Owner isn't sure if the dog at the missing part or if the mice did. Dog is normal now. When the owner originally saw the blue in the dog's stool this am, she thought that it was because the kids had fed the pup blue crayon bits. The kids said that they didn't. Now the owner wonders if the dog had actually gotten the product some time before today's observed exposure. The owner took the dog into the vet and the dog is currently being treated with Vitamin K. Status unknown.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here