Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-3272

2. Registrant Information.

Registrant Reference Number: 1979087

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.

10-JUL-08

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-JUN-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. 9103      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Lawn WeedOut Concentrate

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
  • MECOPROP (PRESENT AS DIMETHYLAMINE SALT)

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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).

Caller indicated that he applied the product to his lawn with wearing any protective clothing. He also indicated that he did not read the label for directions of use.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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 up blood

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Shakiness
  • Symptom - Muscle pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

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)

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

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

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 had been applying a herbicide over the last three days without any protective clothing. He also indicated that during those three days he had been breathing in the drift coming off the product when applying. He did admit to not peeling back the label to read the directions, instead he just pulled the label off removing the entire label. Caller is now experiencing symptoms of vomiting, coughing up blood and legs aching as a result of the dermal and inhalation exposure. The operator who fielded the call explained to the caller to seek medical attention immediately as these symptoms are most likely not related to this exposure. They also explained that it is possible for respiratory irritation from inhaling the mist. Outcome unknown as caller was unable to be contacted from the number given.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

We believe this product was not used in accordance to the label as the caller clearly stated that they did not read the label for direction of use and mostly mixed the product at a much higher strength increasing his exposure level to the product. Also he did not use any personal protective clothing as the label states they should.