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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4284

2. Registrant Information.

Registrant Reference Number: 4319167

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 11913      PMRA Submission No.       EPA Registration No.

Product Name: CIL Diazinon 12.5 Concentrate

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Difficulty Breathing

4. How long did the symptoms last?

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

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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 he had a container of CIL diazinion 12.5 % on a shelf in the basement, he noticed one day ago it was leaking and soaked up most of it with rags. Since then the furnace had pulled the odor up into the rest of the home, his wife noticed odor about 2030 last night. Caller wants to know how to do clean up the rest as there is a chemical odor all through out the home. He is aware product is an organophosphate. Caller has indicated that his wife woke up this morning with difficulty breathing but thinks it is from the odor no other symptoms. Her symptoms seem to have cleared up since she went out into the fresh air. the caller was recommended to call the fire department to clean up spill. Also relayed best to sleep elsewhere until odor gone from home. caller indicates he has most of spill contained and just wants directions on how to complete clean up and does not want to call the fire department. relayed per MSDS " Stop leak, contain spill by diking and absorb with suitable absorbent and transfer into waste container for disposal. Clean area with detergent and water, absorb wash and place in waste container." caller declined CB he will CB if they have any further symptoms.

To be determined by Registrant

14. Severity classification.


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.