Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2789

2. Registrant Information.

Registrant Reference Number: 4513465

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.

02-NOV-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

01-OCT-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. 28352      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat and Mouse Killer Blok

• Active Ingredient(s)
  • DIFETHIALONE

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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).

unknown

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

Parson Russell Terrier Mix

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

15

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Abnormal feces colour
  • Symptom - Diarrhea

• General
  • Symptom - Vocalizing

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

The owner does not know when or how much the dog ingested of this agent but she saw today traces of blue/green bait in the stool. Also, Montana yelped twice in the morning. The owner was advised that because the amount was unknown consistent, the patient was considered to be at high risk of developing clinical signs. If signs develop, there is high risk that those signs will be life-threatening. Advised owner to take the animal into their DVM. On October 7 during a follow up call the owner stated that the dog is doing ok at home. She had really bad diarrhea that first night, since then has gotten better. She is eating grass now. Her stools were orange up until yesterday. Spoke with (name) to make sure everything sounded good for this pet. She said the vitamin k1 length was a good time-frame. She recommended contacting her Reg DVM and asking them if she needed some GI protectants, such as pepcid. She said to make sure they are giving the vitamin k1 with a high-fat meal to assure that it's not making her nauseous and is absorbing correctly. She said she had a list of things to watch for from her veterinarian and will call if she sees any of them. Owner was advised that she could have her RegDVM call to consult about the pepcid since the owner is concerned about putting her on too much medication. Final outcome unknown

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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.