Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4676
2. Registrant Information.
Registrant Reference Number: 1995478
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.
13-AUG-08
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
17-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)
PMRA Registration No. 26679
PMRA Submission No.
EPA Registration No.
Product Name: Green Earth Ant Roach Insect Dust
- Active Ingredient(s)
- SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS
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. - In Home / Rés. - à l'int. 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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
8
7. Weight (provide a range if necessary )
18
lbs
8. Route(s) of exposure
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Rectal hemorrhage
- Specify - Bleeding from the rectum
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?
Unknown
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The caller states her mom's dog may have been exposed to the Green Earth Ant and Roach Insect Dust placed down under the rug a couple of days ago and also off and on for a couple of weeks, the dust is covered by a rug but he dog food is next to the rug and may have walked through some of the dust last night at about 6pm. The dog stopped eating and the dog was bleeding out of rectum and penis last night and taken to the vet, he has been at the vets since last night and just came home from the vet and was told the dog may die and asking if the dog into any roach or ant killer with warfarin? The dog is a terrier poodle mix. The operator advised the caller that the registration number she referenced contains only the active called Diatomaceous Earth (Silicon Dioxide) and doubts that the symptoms that the dog is exhibiting is related to this product.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
We do not support the claims of this case as diatomaceous earth has been found to be non toxic to both animals and children.