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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4296

2. Registrant Information.

Registrant Reference Number: 4355512

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.

11-MAR-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

03-FEB-10

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. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat and Mouse Bait

  • Active Ingredient(s)
    • BROMADIOLONE

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

Maltese

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

5.0

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

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

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?

No

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

Dog have had access to the bait yesterday. Dog vomited a couple of time last night and vomitus seems to have blue color in it. Because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is high risk that those signs will be life-threatening. The animal owner was advised that vomiting may be from something else. With this exposure, internal bleeding can occur in 3-5 days after exposure. At 2:25pm February 03, the animal was taken into the vet. Vet staff (name) called in to discuss Vitamin K1 doses. At 4:13pm the owner called back to discuss the situation. She's wondering if there's anything more she can do beyond treating the dog with vitamin k1. She's on 6 mg BID. I asked her to give it with food and continue x 21 days. Follow up with a PT time. On February 13, the owner was contacted for a follow up. The pet has been on this medication for 10 days. She is due to refill the medication. She wants to know that since she has been doing well if they need to keep giving this to her. The owner was advised to keep the animal on this for the next 21 days. Even though she looks normal, if she goes off of the Vitamin K1 before 21 days, she could start having trouble clotting her blood. The pet gets hyperactive after she gets her Vitamin K1. Is this normal? They are giving the injectable by mouth. Could be a taste reaction, give a treat and then take her for a walk and see if that helps


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.