Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2301

2. Registrant Information.

Registrant Reference Number: 4031215

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.

10-DEC-08

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

17-NOV-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. 9802      PMRA Submission No.       EPA Registration No.

Product Name: Wilson 50% Malathion

• Active Ingredient(s)
  • MALATHION

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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).

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.

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 - Pruritus

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?

Unknown

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?

Unknown / Inconnu

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 says he was told by a (name) to use product indoors to get rid of bedbugs. He says he feels kind of itchy periodically since then and is wanting clean up info. (name). No rx, (name). The caller was advised that it is unlikely that symptoms are related but he should see MD since symptoms are persisting and also to contact company customer service for clean up info. Gave what info re clean up from MSDS. The caller was also advised that any leather must be disposed of and cannot be cleaned. He sprayed some in his care that has some leather on seats.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

This particular use of the Malathion product was not used in accordance with the label. The label for Wilson Malathion 50% clearly states that this product cannot be used in doors.