Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4682

2. Registrant Information.

Registrant Reference Number: 2027354

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.

31-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. 26179      PMRA Submission No.       EPA Registration No.

Product Name: CIL Flea Killer Surface Spray

• Active Ingredient(s)
  • D-PHENOTHRIN
  • PYRIPROXYFEN
  • TETRAMETHRIN

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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: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Conjunctivitis
  • Symptom - Irritated eye
  • Symptom - Red eye
  • Symptom - Burning 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)

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 her son who is (age) years old, who has kidney problems/no medication/ no known allergies. Her child got this product in both of his eyes, red, burning sensation, left eye feeling has the feeling of something in the eye. His vision is clear. Time of exposure: 10mins ago The caller was advised that transient ocular irritation is possible. Tissue injury is not expected if eye is promptly and adequately irrigated. Recommendation to Irrigate eye(s) for 15-20 minutes under a gentle stream of comfortable temperature water. Do not hold eyelid(s) open, but slowly blink. Rest eye(s) after irrigating. No eye drops or ointments. Cool compress to closed eyes as needed. If symptoms continue or worsen over the next 1 to 2 hours, then an eye exam will be indicated During a follow up call and hour later the caller indicated that symptoms have resolved.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.