Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5438

2. Registrant Information.

Registrant Reference Number: 4480527

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.

08-SEP-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

11-AUG-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)

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PMRA Registration No. 26720      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth HomeCare Flying and Crawling Insect Killer

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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).

sprayed her bedding with Green Earth Home Care Flying and Crawling Insect Killer

To be determined by Registrant

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

No

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Pruritus

4. How long did the symptoms last?

Unknown / Inconnu

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)

Application

Contact with treated area

What was the activity? sprayed her bedding

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

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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.)

(age) old female has sprayed her bedding with Green Earth Home Care Flying and Crawling Insect Killer a bit for the past 3 months,was not suppose to use on her bedding but did put it on her quilt. Has noticed a generalized pruritis , wonders if paranoid about the bed bugs ? Has not noticed any bugs or bites. Caller was advised to decontaminate the bedding, also may use a vitamin E lotion to treat her skin return.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

This product was not used in accordance with the label, the exposed caller even admitted that she should not have used it on her bedding, but decided to any ways. This exposure was a result of the consumer having no regard for the label instructions.