Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5515

2. Registrant Information.

Registrant Reference Number: 4686820

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: NEW BRUNSWICK

6. Date incident was first observed.

28-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)

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PMRA Registration No. 21936      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant Killer Dust

• Active Ingredient(s)
  • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Golden Retriever

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

60

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 - Bloody diarrhea
  • Symptom - Vomiting

12. How long did the symptoms last?

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

13. Was medical treatment provided? Provide details in question 17.

Yes

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

DVM calling because the pet was exposed to Wilson Ant Out Dust approx. 24 hours ago. Pet ingested an unknown amount of the product. Pet is symptomatic at this clinic. Pet has bloody diarrhea and is vomiting bile. Pet is at the DVM at this time. Per the DVM, this dog ingested this off the ground. Unknown what else might have been on the ground that the dog may have ingested. Because the amount was somewhat consistent, the patient was considered to be at medium risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. Ingestion of this agent may cause GI upset secondary to dietary indiscretion. More significant signs are not expected. The severity of this dog's signs suggest another etiology. Discussed case with DVM and explained that while this agent can cause mild, typically self limiting signs, the severity and time of onset of this dog's signs suggest a different etiology. Also, with the amount ingested being only what the dog could have picked up off the ground, it is unlikely that the dog got enough to cause more than mild signs. I suspect this dog ingested something else off the ground at the time of this exposure or that this is not a toxin-related event. Consider alternate causes for this dog's signs. Symptomatic and supportive care. Call back with questions or concerns.

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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.