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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2225
2. Registrant Information.
Registrant Reference Number: 1892468
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.
10-MAR-085. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
20-FEB-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. 26679 PMRA Submission No. EPA Registration No.
Product Name: Green Earth Ant and Roach Insect Dust
- Active Ingredient(s)
- SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS
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
Cat / Chat
3. Breed
Persian
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.08
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Eye
- Symptom - Pupil dilation
- Nervous and Muscular Systems
- Symptom - Loss of coordination
- Specify - slow reflex
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
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
Caller stated that their animal may or may not have been exposed to some Diatomaceous Earth. Animal is in good health, no medication. The owner expressed concerns about the animal displaying symptoms of slow reflex response and dilated pupils. When the operator offered to transfer them to a vet on call they refused and hung up.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
