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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-5446

2. Registrant Information.

Registrant Reference Number: 1949608

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.

11-JUN-08

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-MAY-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. 25300      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Total WipeOut (RTU)

  • Active Ingredient(s)
    • GLUFOSINATE AMMONIUM

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: Pub. Area - Outdoor/Zone publique - ext

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • Nervous and Muscular Systems
    • Symptom - Dizziness

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)

Long-sleeve shirt

Long pants

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

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

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 is (age) yo male who lives in retirement home, he states he applied Wilson's Wipe Out RTU herbicide yesterday x 30 mins, used nearly entire bottle. This was in an area several miles away from residence. He states that he didn't feel well afterward, drove home to sleep, felt better. Then vomited twice yesterday evening, and also fell last night but states he `didn't hurt himself`. He is in bed this morning, feels very dizzy. Recommendation? Did not shower or wash off after application. Recommend not to shower now due to dizziness and fall. Advise to go seek medical evaluation now for these symptoms, MD or patient to call for any questions. Follow up call on May 17, 2008, the caller states he feels a little better today. Did shower yesterday. Plans to see MD on Monday. He declined any further Call backs.. Residence nurse say him yesterday and again states he did not have an injury from the fall except knee hurting. Has a history of injury to that knee.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.