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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4615
2. Registrant Information.
Registrant Reference Number: 1961534
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.
12-JUL-085. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
02-JUN-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. 27492 PMRA Submission No. EPA Registration No.
Product Name: Wilson Riddex Bloks Rat 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
Miniature Pinscher
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
8
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 - Bloody diarrhea
- Symptom - Diarrhea
- Symptom - Vomiting
12. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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
Fully Recovered / Complètement rétabli
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 stated that they suspect another family member had put out some rodenticide. Dog may have ingested 1/4 of a 28g block, but not verified. It was noted on June 2, 2008 that the animal was exhibiting clinical symptoms of initial diarrhea, than followed by bloody diarrhea and isolated vomiting. On June 11, 2008 a follow up call was given to the clinic that treated the animal initially and a vet technician had indicated that the animal was not put any vitamin K as per the vet's request since the animal has not displayed any further symptoms as of June 9, 2008. They have concluded that the animal was not exposed to an anticoagulant.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
