Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-2226

2. Registrant Information.

Registrant Reference Number: 1913620

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.

09-APR-08

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

24-MAR-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. 14703      PMRA Submission No.       EPA Registration No.

Product Name: CIL AntOut - Liquid Ant Killer

• Active Ingredient(s)
  • BORAX

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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. - In Home / Rés. - à l'int. 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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• Cardiovascular System
  • Symptom - Abnormally fast heart rate

4. How long did the symptoms last?

<=30 min / <=30 min

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

No

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)

Contact with treated area

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

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 stated that he was using a liquid ant killer product containing a borax solution for approximately 5 minutes s and is now experiencing coughing and a rapid heart beat after cleaning up the product. Caller indicated that he currently takes blood pressure medication, however after 30 minutes since the exposure he feels heart rate improving with the cough lightening up. the operator who fielded the call advised the caller that Increased heart rate is not an anticipated symptom from inhalation of this particular active. However recommended that if he continues to experience symptoms to 1) Ventilate indoor areas, fresh air for 30-60 minutes. 2) If symptoms persist, inhale steam from shower. 3) If difficulty breathing, persistent cough, or prolonged symptoms occur, seek medical attention.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.