Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4681

2. Registrant Information.

Registrant Reference Number: 2026531

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: NOVA SCOTIA

6. Date incident was first observed.

30-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. 14058      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Mouse Treat

• Active Ingredient(s)
  • CHLOROPHACINONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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 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: <=1 yr / < = 1 an

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Lethargy

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)

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 her nephew may have ingested a couple treated seeds of the Wilson mouse treat. Wants to know what the symptoms a child might experience. Child was on floor `rolling around` in the area, no known exposure, taste of a couple seeds if any. Child seems lethargic now, asks if this is related. The caller was advised that the active for this product is an anticoagulant and symptoms may include easy bruising and bleeding gums, not expected that these symptoms would have occurred this quickly. Lethargy not related. If any of the symptoms should appear than seek medical attention right away. Caller denied follow up call. Outcome unknown.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.