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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4617
2. Registrant Information.
Registrant Reference Number: 1967968
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: MANITOBA
6. Date incident was first observed.
10-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. 9222 PMRA Submission No. EPA Registration No.
Product Name: CIL Warfarin Rat and Mouse Bait
- Active Ingredient(s)
- WARFARIN (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
German Shorthaired Pointer
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.42
7. Weight (provide a range if necessary )
45
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
- Skin
- Symptom - Pallor
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
Caller informed that their dog had chewed into a 250 g package and could have ingested up to 1/3 of the bait The owner was advised to take the animal into the vet as the animal was considered to be at risk. The next day they took their dog into the vet first thing, the vet started the dog on Vit K1 and discharged the dog. The next morning on the dog's gums appeared white and so was advised by the vet to bring her back in. A coagulation test was preformed and the blood clotted. Outcome unknown
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
