Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5370

2. Registrant Information.

Registrant Reference Number: 4941761

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.

13-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

12-AUG-12

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. 27492      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Riddex Bloks Rat And Mouse Bait

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)

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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: Unknown / Inconnu

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

Irish Terrier

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

40

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Drooling

• Nervous and Muscular Systems
  • Symptom - Trembling

12. How long did the symptoms last?

Unknown / Inconnu

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

No

14. a) Was the animal hospitalized?

No

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 believes the exposure happened sometime between 7:30am-10:15am (EST). Owner found the stations that held the bait licked. Owner doesn't know how much, if any, could have been ingested. The dog has vomited many times - foam. Owner states 10x total in the hour. His jaw is also trembling after he vomits. The caller was advised that the severity of vomiting is concerning. Owner wants to determine all baits involved. Regardless, the dog should be seen now to control the vomiting, then treat the rodenticide exposures. Provided the owner the case information. Asked owner to call back with questions. Have DVM call to discuss the case. On August 14, 2012, during a follow up call, the caller advised that the vomiting had stopped on it's own. Owners have not yet taken dog to DVM. They spoke with a friend who is a veterinarian and it sounds as if they opted to monitor at home. They think only remnants may have been ingested. Per vet friend. It would not take much to reach a concerning dose of this ingredient for Jesse (amount roughly equivalent in weight to 1.5 American nickels It would be best to have a PT time checked tomorrow (8/15) morning at the least. Signs may not develop for several days post exposure and are not always visible externally.

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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.