Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4652

2. Registrant Information.

Registrant Reference Number: 1989308

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: BRITISH COLUMBIA

6. Date incident was first observed.

09-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. 25301      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Total WipeOut (Concentrate)

• Active Ingredient(s)
  • GLUFOSINATE AMMONIUM

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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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

<=30 min / <=30 min

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

Unknown

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

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 stated that he mixed some Wilson's Total WipeOut into a sprayer and the handle fell apart and separated. The product got all over shirt and some got into right eye 20- 30 minutes ago. He is currently feeling some irritation in that right eye. He is (age) years old and wears no contact lenses. The caller stated that he has already used an eyewash bottle 15minutes ago. The caller was further advised to do a 20 minute luke warm irrigation to with blinking motion being performed and then to apply cool compress afterwards. Outcome no further symptoms

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

We would like to make note that the sprayer used by the consumer was not a sprayer designed and sold by our company and therefor we are only reporting it as a human exposure rather than a packaging or equipment failure.