Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5373

2. Registrant Information.

Registrant Reference Number: 4944480

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.

12-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

16-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. 13570      PMRA Submission No.       EPA Registration No.

Product Name: Laters Creeping Buttercup Weed Killer

• Active Ingredient(s)
  • MCPA (PRESENT AS AMINE SALTS: DIETHANOLAMINE, DIMETHYLAMINE, OR MIXED AMINES)

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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: 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).

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 - Irritated skin

• Eye
  • Symptom - Irritated eye

• General
  • Symptom - Chemical taste in mouth

• Nervous and Muscular Systems
  • Symptom - Dizziness

• General
  • Symptom - Other
  • Specify - hot heads

• Nervous and Muscular Systems
  • Symptom - Tingling in mouth
  • Specify - cheeks tingling

• Eye
  • Symptom - Burning eye

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)

Unknown

10. Route(s) of exposure.

Oral

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.)

TC from caller stated that he has used this product and has come down with sxs. Caller has had a hx of a heart condition in the past. Caller has been using this to kill a horse tail (used 1x day everyday) (spring 1x daily) After using the product he would go about his day as normal. Caller is gh, no meds, nka Caller: O. 6/29/12 light headed, woozy Bitter burning taste in mouth over 2 months . Hot heads, cheeks tingling, eyes burning sensation R. PC stated would expect sxs to occur sooner. PC advised to stay under the care of (name) office.

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.