Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4721

2. Registrant Information.

Registrant Reference Number: 2032597

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.

14-OCT-08

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

08-SEP-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. 26208      PMRA Submission No.       EPA Registration No.

Product Name: CIL House and Garden Insect Killer

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

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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: 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).

caller stated that she sprayed quite a bit of the room, all over on the couch and everywhere else.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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

• Skin
  • Symptom - Hives
  • Symptom - Pruritus
  • Symptom - Erythema
  • Symptom - Itchy skin

• Eye
  • Symptom - Red eye
  • Symptom - Itchy eye

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

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.

Skin

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

Telephone call from a spouse stating that her husband sprayed quite a bit of the room with the product and all over the couch and everywhere else. Caller stated that he was working with this for 45 minutes, before he took a shower. husband, (name), no meds, nka. Time of exposure 1 day ago. About a half hour later her husband was experiencing after hives, raised red itchy, legs, hands, arms, eyes. the caller was advised to discontinue using the product and to seek medical advice becuase symptoms are persistent. Caller was also advised to wash exposed skin with luke warm water.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.