Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4673

2. Registrant Information.

Registrant Reference Number: 2018253

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.

15-SEP-08

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

18-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)

PMRA Registration No. 27492      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Riddex Bloks Rat and Mouse

  • Active Ingredient(s)
    • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)

7. b) Type of formulation.

Application Information

8. Product was applied?

No

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

Border Collie

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.67

7. Weight (provide a range if necessary )

25.0

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

  • General
    • Symptom - Lethargy
  • Nervous and Muscular Systems
    • Symptom - Depression
    • Symptom - Disorientation

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?

Yes

14. b) How long was the animal hospitalized?

4

Day(s) / Jour(s)

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

Owner found the empty box of rodenticide 4 days ago and didn't think much of it. Just thought it was an old box out in the barn. Dog could have gotten up to 10 blocks, but not sure. Owner just noticed the dog seemed depressed around 9am today. At the vets they noticed her gums are white, she's very weak, and a little disoriented. Vet did an exam and is going to start the dog on Vitamin k and fluids, but hasn't run blood work. Owner is calling from home, dog is still at the clinic (on Aug 18, 2008 at 06:35 PM) Dog is abnormally skinny, but vet says its because she is high energy, and is outside all the time, running around. Consultation on treatment was conducted with Veterinarian and was advised that this agent is a second generation anticoagulant. Common signs include: lethargy; depression; bleeding from nose or rectum; and internal bleeding. Signs usually develop 3-5 days post exposure. During a follow up call with the Clinic, the Clinic stated that the dog was fine still being treated with the Vit K1. There was a language barrier they were not able to specify if and when the signs ceased. (Aug 22, 2008 at 07:28 PM)


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here