Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-5452

2. Registrant Information.

Registrant Reference Number: 1958526

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.

28-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)

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PMRA Registration No. 17971      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Liquid Sevin Insecticide

• Active Ingredient(s)
  • CARBARYL

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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. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Applied product to a small ornamental tree.

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: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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)

Contact with treated area

Amount of time between application and contact 9

Hour(s) / Heure(s)

What was the activity? Daughter shook tree

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.

Skin

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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 he applied the product to one of his trees in the morning. 9 hours later his (age) year old daughter shook the tree twice and the mother of the child (name) told her to not shake the small tree ((name) did not know that the tree had been sprayed). She then came in and ate some food without washing hands. 2 hours after exposure, wife reports that daughter complained that she was experiencing nausea (like she was going to vomit). Child went to sleep 2.5 hours ago and seems fine. The operator who fielded the call informed the caller that it is unknown as to whether the symptoms were caused by exposure given the time frame. Follow up call denied.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.