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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4159

2. Registrant Information.

Registrant Reference Number: 4223529

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-SEP-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

17-AUG-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)

PMRA Registration No. 27587      PMRA Submission No.       EPA Registration No.

Product Name: CIL Jet Foam Wasp and Hornet Killer

  • Active Ingredient(s)
    • D-TRANS ALLETHRIN
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN

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: Unknown / Inconnu

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

Sprayed until contents were emptied

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

  • Cardiovascular System
    • Symptom - Tachycardia
  • Skin
    • Symptom - Blister
    • Symptom - Burning skin
    • Symptom - Erythema
    • Symptom - Irritated skin
  • Respiratory System
    • Symptom - Respiratory distress

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?

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)

None

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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 the afternoon of August 16, 2009, at which the contents in the can were emptied within 5 minutes. His arms, nose and legs were exposed to the product. He did not immediately wash the exposed areas of his body after using the product, he then indicated that he had showered at around midnight that night. He noted a blister started to form at around 5pm and then redness one to two hours later. This morning his chest, arms, and legs are red and bubbles all over, feels hot to the touch. The caller was recommended to go immediately to the emergency department. He stated that he would go his family physician at 9am and will follow up in two days. The next day during a follow up call the caller explained that he went to see his doctor, whom prescribed Reactin Pills (allergy relief pill) and some cream. He indicated that his symptoms were getting better but last night they had come back again. Now he is doing better. Will see how it is tonight. Two days later during another call back the caller indicated that he had another reaction which he then took 5 doses of medication, which temporarily resolved the symptoms. 3 hours later the skin began to get hot and started to bubble. On August 28, 2009 the caller inquired as to why this product is not carried in Canada anymore. He went to the store where he originally purchased the product and that is what "the store had told him". He is currently still experiencing the same symptoms and now is having difficulty breathing. He also explained that his doctor is on vacation and that the one covering isn't very good. The caller was advised to wait for his doctor to return from their vacation and if they had any questions to have them call in. Outcome unknown

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