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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2806

2. Registrant Information.

Registrant Reference Number: 4624185

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-MAY-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

14-APR-11

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. 26262      PMRA Submission No.       EPA Registration No.

Product Name: CIL Yard and Deck Insect Killer

  • Active Ingredient(s)
    • D-TRANS ALLETHRIN
    • PIPERONYL BUTOXIDE

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 in basement

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Burning throat
    • Symptom - Difficulty Breathing
  • Eye
    • Symptom - Dry eye
  • Respiratory System
    • Symptom - Respiratory irritation
    • Specify - lungs are irritated

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)

Contact with treated area

What was the activity? accessing basement

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.

Eye

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 stating that the cleaning lady saw ants in the basement and sprayed with the product all around the baseboards. She has to go to get meds from the basement so she has to go back and forth. Caller has been having a sxs to the product. Caller says she is in good health and is on no meds. Caller claims to have the following symptoms: hard to breathe, burning sensation, dry in eyes, throat feels dry, lungs are irritated. Caller was advised to gently rinse skin well under gentle stream of comfortable temperature water for 15-20 minutes. May also wash with mild soap. For minor irritation, may apply vitamin e-oil. Irrigate eye(s) for 15 20 minutes under a gentle stream of tepid water. Do not hold eyelid(s) open, but slowly blink. Rest eye(s) after irrigating. No eye drops or ointments. Cool compress to closed eyes as needed. If symptoms continue or worsen over the next 1 to 2 hours, then an eye exam will be indicated. Call us back if sxs persist after irrigation. Dilute with 8 oz for adults water, if necessary breathe in steam, keep hydrated and get fresh air. Stay out of area till smell is gone and do not use the product indoors. CB declined.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

This product was used in contravention of the label. Label instructions explicitly state for use outdoors, in garages and or covered patio's. Label does not make any mention of indoor house use. 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.