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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4823

2. Registrant Information.

Registrant Reference Number: 4205530

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.

Domestic Animal

4. Date registrant was first informed of the incident.

13-AUG-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

21-JUL-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. 27017      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Ant Trap

  • Active Ingredient(s)
    • BORAX

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).

unknown

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Weimaraner

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

65

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy

12. How long did the symptoms last?

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

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Owners children saw patient with ant trap in its mouth yesterday morning 7/21/09 between 8-9amCT. Owner doesn't believe all of the substance was consumed but a lot did leak out into animal mouth. Animal started vomiting this morning 7/22/09 around 1000CT- white foam. It was explained to the animal owner that normally we would expect to see vomiting signs within the first few hours of ingestion and not 24 hours later. With ingestion being 24 hours ago the time frame this doesn't sync up with the symptoms. If patient is still vomiting or has any other signs we would want the owner to take patient into her veterinary clinic. Also owner should look around the house for any more traps or other substances that the patient might have gotten into this morning. If any problems or questions arise we want her to give us a call back. Owner calling in with a question. She has not been home with Diva today, her children have, so she is getting the information second-hand. She states that Diva vomited 2 more times recently and seems lethargic. She does not know if the initial episode of vomiting was managed per our instructions. She thinks Diva ate a little bit earlier today, but she is not certain. The owner was recommended at this point in time Diva needs to be evaluated by a DVM. It is highly unlikely that the situation is related to an exposure to the ant trap. Call with any questions.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. 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.