Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2790

2. Registrant Information.

Registrant Reference Number: 4514306

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.

03-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. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat and Mouse Bait Pellets

• Active Ingredient(s)
  • BROMADIOLONE

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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

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

.83

7. Weight (provide a range if necessary )

15

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

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

• General
  • Symptom - Lethargy

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Owner stated that between maybe about 8p last night to around 6a CDT today one or both dogs acquired one packed may have ingested 40g. This is the 1st known exposure. Owner was advised that because there were symptoms to one of his dogs that the owner may want to try and induce enemis. The owner was given proper instructions on how to induce. Owner called back with an update. Owner gave 2 doses of H2O2 with no effect. Rocky did pass solid stool that was green. Owner DID induce in Duke and he did vomit, but no bait was recovered. Owner has K1 left over from another exposure. Discussed with owner. Since there was green material in Rocky's stool (seen at time peroxide administered), exposure time likely at least 16-18 hours ago - late afternoon or early evening yesterday much more likely than over night. Recommended run PT on Duke at 48 hour mark. Rocky will need K1 for 3-4 weeks. On October 18, 2010 during a follow up call the owner had some questions about lethargy as a result of the vitK1. The owner was advised that symptoms would not expected as result of this. Take animal to regDVM.

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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.