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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4287
2. Registrant Information.
Registrant Reference Number: 4337312
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.
10-FEB-105. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
05-JAN-10Product 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. 28352 PMRA Submission No. EPA Registration No.
Product Name: Wilson Predator Rat and Mouse Killer Blok
- Active Ingredient(s)
- DIFETHIALONE
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
Labrador Retriever
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
30
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Fasciculations
- Symptom - Agitation
- Symptom - Ataxia
- Symptom - Trembling
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Was medical treatment provided? Provide details in question 17.
Yes
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
The owner does not remember if there were 2 or 3 bars on the table and now he has only 2 left. He suspects that the dogs may have ingested 1 bar around 0745 CST. The animal owner was informed that because the time course was poorly consistent, the amount was somewhat consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation. The animal was taken into the local vet because the owner did not have any H2O2 to help try and induce vomiting and that it would take him at least 1.5 hours to get some. Vomiting was induced at the vet and the animal has now started exhibiting symptoms around 9am. It was explained to the vet that CNS signs would not be expected. During a routine follow up call two days later, it was learnt that the animal has gotten better later that day but has been on K1 since yesterday.
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.
