Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4671

2. Registrant Information.

Registrant Reference Number: 2009918

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.

08-SEP-08

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

06-AUG-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. 27587      PMRA Submission No.       EPA Registration No.

Product Name: CIL Jet Foam Wasp and Hornet Killer

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

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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: Unknown / Inconnu

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

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain
  • Symptom - Red eye

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)

None

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.)

The caller's dad was sprayed in the both eye with CIL Jet Foam Wasp and Hornet killer, he has been rinsing eyes at the sink for the past 5 minutes. Both eyes are irritated, red no contacts worn, also spoke with the patient and his wife (name) The son of the exposed patient was advised to have his father Irrigate eyes with gentle stream of lukewarm temperature water for about 15-20 minutes. Do not hold the eye open, Do not use eye drops. If symptoms of pain, redness, irritation or visual disturbances persist, seek immediate opthalmic evaluation. During a follow up call the following day the wife conveyed that her husband is doing fine and that all symptoms have resolved.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.