Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2824

2. Registrant Information.

Registrant Reference Number: 4635029

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.

10-JUN-11

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

02-MAY-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. 26699      PMRA Submission No.       EPA Registration No.

Product Name: Wilson GrubOut Ant and Grub Killer

• Active Ingredient(s)
  • CARBARYL

---

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. - Out Home / Rés - à l'ext.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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Blister

• General
  • Symptom - Swelling

• Skin
  • Symptom - Burning skin

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Long-sleeve shirt

Long pants

10. Route(s) of exposure.

Skin

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 stated that us used Wilson grub out ant and grub killer (attachment and spray not concentrate) to treat worms in his lawn and later sat on the grass where the product was. No direct contact with product with any skin that he is aware of. His skin was covered when he sat on the grass. Good health except heart surgery x 2 Symptoms: he has had swelling and blisters on the top area of his hip, burning and itching also. He has been putting calamine lotion on area, since he started applying calamine lotion the blisters are drying out. TOE was Friday during the day he showered and washed off skin Friday evening prior to going to bed, he noticed Friday night that he had pimple areas on that hip and then Saturday Am noticed that area was blistered. Caller was recommended to consult with pharmacist about OTC treatment for sxs. If no relief of sxs then will need to see PMD. caller indicates his wife has an appt with PMD tomorrow and he will go along to have PMD look at area.

To be determined by Registrant

14. Severity classification.

Minor

15. 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.