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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5507

2. Registrant Information.

Registrant Reference Number: 4677715

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.

11-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

04-JUL-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. 27901      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ready To Use Indoor/outdoor Spray

  • Active Ingredient(s)
    • PERMETHRIN

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).

Sprayed inside garage

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

Border Collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

50

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

  • Respiratory System
    • Symptom - Dyspnea
  • Nervous and Muscular Systems
    • Symptom - Restlessness
  • Respiratory System
    • Symptom - Heavy breathing
    • Symptom - Panting
  • General
    • Symptom - Abnormal behaviour
    • Specify - ears are back
  • Eye
    • Symptom - Pupil dilation
    • Specify - dilated pupils

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

Fully Recovered / Complètement rétabli

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 indicated that the dog may have gotten into some of this agent as her dad was spraying the garage 4 hours ago. She is unsure if an exposure occurred. Dog became symptomatic about 2 hrs ago. Dog is restless, experiencing heavy breathing, and has dilated pupils. The dog is currently eating and drinking normally. Owner also noted that the dog's "ears are back." (Jul 04, 2011 at 10:50 PM). The caller was advised that the use of most premise sprays as per label directions is not expected to cause significant clinical signs. The concentration of active ingredients is typically quite low, so even ingestion of the agent via licking treated surfaces does not pose a significant threat of toxicity. A taste reaction may occur and, if enough is ingested, we may see mild, typically self-limiting GI signs. More severe signs are not expected. If an animal is in an enclosed area when this type of product is used and does not have access to fresh air, we can see respiratory irritation. Typically this will be mild and self limiting and will resolve once the animal is removed to fresh air. The signs in this case are not likely related to agent exposure, especially in light of the fact that there is no known exposure in this case. During a follow up call the next day it was learnt that the animal had slowly gotten better overnight and was back to normal by the morning.


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.