Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4632

2. Registrant Information.

Registrant Reference Number: 1972019

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.

12-JUL-08

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

16-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. 26923      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Ant Killer Dust

• Active Ingredient(s)
  • CARBARYL

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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: Other / Autre

Préciser le type: Outside Residential and Inside as well

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

states that he sprinkled some of the product around the outside of his house and a little inside (little bit in the heater vent.)

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.

Other

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Diarrhea

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

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 states that he sprinkled some of the product around the outside of his house and a little inside (little bit in the heater vent.) Daughter started developing symptoms Thursday night. Last night she went to the ER for persistent symptoms. Trying to determine if symptoms are related to the product or not. Girl is in good health, no known allergies and no medication. Not a confirmed exposure. The operator explained to the caller that because it was not a confirmed exposure it is hard to determine if the symptoms were a result of being exposed to the product. However they should continue to monitor for persistent or worsening symptoms while keeping the patient hydrated. Clean up areas where product was applied real well to ensure no further exposures. Outcome unknown follow up call could not be completed.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

This product does not have an approved indoor use on the label and therefor was a misuse of product.