Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4309

2. Registrant Information.

Registrant Reference Number: 4372355

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.

Human

4. Date registrant was first informed of the incident.

13-APR-10

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

03-MAR-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. 26719      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Homecare Ant and Crawling Insect Killer

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN
  • PYRETHRINS

---

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).

around baseboards and floors

To be determined by Registrant

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

Unknown

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.

System

• Skin
  • Symptom - Erythema
  • Symptom - Pruritus
  • Symptom - Rash

• Respiratory System
  • Symptom - Respiratory distress

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 2

Hour(s) / Heure(s)

What was the activity? re-entry into the house

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

None

10. Route(s) of exposure.

Skin

Respiratory

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 her husband sprayed the product last night around the baseboards and floor. They left the house and came back approximately 2 hours later. The patient had a nose bleed (1 time) last night. She used a topical Benadryl medication on her skin. The patient has chemical sensitivity - allergies to different types of products. She is currently seeing a Homeopathic professional and takes Desensitization agents for her allergies. The caller was recommended to: 1. gently wash skin well under comfortable temperature water for 20 minutes. 2. May also wash with mild soap. 3. If symptoms persist to seek medical. During a call back the following day the caller stated she was able to call and speak w/her Homeopathic doctor who believed her symptoms were related to the product. She was instructed to perform Epsom salt baths and to use the sauna. She stated she is feeling a little better. Nose bleed - resolved, rash - improved, redness and itching - improved and chest tightness has resolved.

To be determined by Registrant

14. Severity classification.

Minor

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.