Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-1269

2. Registrant Information.

Registrant Reference Number: 4111142

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.

13-APR-09

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

21-MAR-09

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. 27017      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Ant Traps

• Active Ingredient(s)
  • BORAX

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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.

Data Subject

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 - Erythema

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Fainting
  • Specify - syncope

• Skin
  • Symptom - Pruritus

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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 used a knife to cook with that he had used to open up the product with PCP # 27017 Wilson ant traps. He indicated that he had washed off the knife prior to him using it to cook with. He has seen MD about his symptoms and MD gave him benadryl to take for the next 2 weeks. Symptoms that he experienced the next day was redness on his stomach which was a little bit itchy, he also had dizziness, fainted and was SOB. Caller is (age) years old, (name) and (name) except when he went to MD, the MD said he had an irregular Heart beat. The caller asked when is the benadryl going to take the dizziness away? The caller also mentioned that he had experienced these same symptoms 2 months prior. The caller was advised that the symptoms mentioned are not related to the exposure, however if he continues to experience them to go back to his PMD for further check up.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.