Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4646

2. Registrant Information.

Registrant Reference Number: 1987699

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.

13-AUG-08

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

07-JUL-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. 9802      PMRA Submission No.       EPA Registration No.

Product Name: Wilson 50% Malathion Liquid Insecticide-Miticide

• Active Ingredient(s)
  • MALATHION

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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).

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Burning mouth
  • Specify - burning tongue

• Respiratory System
  • Symptom - Burning nose

4. How long did the symptoms last?

Unknown / Inconnu

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)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 stating on Saturday her husband was preparing the product for use inhaling if for about 5-10 minutes. After he prepared it, the caller sprayed it in her potato garden. 10 minutes later caller started having a burning sensation in her eyes and nose. 4hours later her husband started feeling weak and dizzy. The next day he started having diarrhea. Caller wants to know if this product could be causing her husbands symptoms. The Operator who fielded the call recommended: 1) It is unlikely the symptoms experienced are related to this product 2) If symptoms persist or worsen, follow up with physician 3) The MSDS can be faxed to the physician 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.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea

• General
  • Symptom - Weakness

• Nervous and Muscular Systems
  • Symptom - Dizziness

4. How long did the symptoms last?

Unknown / Inconnu

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)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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 stating on Saturday her husband was preparing the product for use inhaling if for about 5-10 minutes. After he prepared it, the caller sprayed it in her potato garden. 10 minutes later caller started having a burning sensation in her eyes and nose. 4hours later her husband started feeling weak and dizzy. The next day he started having diarrhea. Caller wants to know if this product could be causing her husbands symptoms. The Operator who fielded the call recommended: 1) It is unlikely the symptoms experienced are related to this product 2) If symptoms persist or worsen, follow up with physician 3) The MSDS can be faxed to the physician 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.