Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4313
2. Registrant Information.
Registrant Reference Number: 4414664
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.
14-JUN-10
5. Location of incident.
Country: CANADA
Prov / State: UNKNOWN
6. Date incident was first observed.
09-MAY-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. 26191
PMRA Submission No.
EPA Registration No.
Product Name: CIL Ant, Roach and Crawling Insect Killer
- Active Ingredient(s)
- D-TRANS ALLETHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- PERMETHRIN
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).
used this product around the base boards of her house
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
Mixed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
15
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller used this product around the base boards of her house about 9 hours ago, and about 6 hours ago her dog began vomiting and acting lethargic. The owner was recommended to take animal to the vet at this time for persistent sxs. Bring product label with you to vet and have your vet call us with questions / concerns. Outcome unknown
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.