Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2305

2. Registrant Information.

Registrant Reference Number: 4044964

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.

09-JAN-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

08-DEC-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. 6944      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Warfarin, Rat and Mouse Killer Pellets

• Active Ingredient(s)
  • WARFARIN (PRESENT IN FREE FORM OR AS SODIUM SALT)

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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 product was applied by landlord in vents because of rodent problem. He can smell a strange smell and it has become worse since heating vents have been turned on. Vents also are full of rodent droppings and possibly dead rodents.

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

• Respiratory System
  • Symptom - Irritated nose
  • Symptom - Other
  • Specify - sores in nose

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)

Contact with treated area

What was the activity? Product was placed in heat duct by the landlord and throughout the place

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.

Respiratory

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 stated that the odor is strong, and he can smell an odor in the home from the vents. He has nasal irritation and has had "sores" develop in nose. Caller also said that the product was applied by landlord in vents because of rodent problem. He can smell a strange smell and it has become worse since heating vents have been turned on. Vents also are full of rodent droppings and possibly dead rodents. The caller was advised that the Inhalation of product may cause respiratory irritation. Recommended that the caller recieve medical attention immediately. Unclear if symptoms are due to inhalation of product or exposure to rodent waste. Gave caller case number, MD may contact if additional information is required.

To be determined by Registrant

14. Severity classification.

Minor

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.