Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4277

2. Registrant Information.

Registrant Reference Number: 4271416

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.

12-NOV-09

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

20-OCT-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. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat and Mouse Bait Pellets

• Active Ingredient(s)
  • BROMADIOLONE

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Standard Poodle

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• General
  • Symptom - Adipsia
  • Symptom - Hyperthermia
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Loss of appetite
  • Specify - Inappetence

12. How long did the symptoms last?

Unknown / Inconnu

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

1

Day(s) / Jour(s)

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

Owner believes that Jingles ingested the bait on the 14th or 15th. A few days later her appetite and water consumption lessened and she became lethargic. She took her to the vet on the 10/18/09 and they ran unknown blood work and put her on IV fluids. Dog was sent home Monday morning (10/19/09) and was back to acting normal, but then started to decline as the day went on. Owner is at home with the dog and calling to find out if this agent is related. The owner stated that the vet did not think that the dogs signs were due to rodenticide ingestion and instructed the owner to continue home care with antibiotics and monitoring. Dog was treated for an anemia condition 2 years ago with steroids, but is normal now. The owner was advised about the anticoagulant rodenticides. She was informed on the amount that she suspected that Jingles had ingested would be enough to be life threatening and she needs to seek treatment right away. I gave her a case number and the follow up number and recommended that she have the vet call back for management details. Outcome unknwon

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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.