Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5386

2. Registrant Information.

Registrant Reference Number: 4940620

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: QUEBEC

6. Date incident was first observed.

10-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. 8352      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat and Mouse Killer Bloks

• Active Ingredient(s)
  • DIFETHIALONE

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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

Jack Russel Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

15

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

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?

Other / Autre

specify ingested a dead poisoned mouse

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The caller stated that she is out of town, staying in the woods and far from town. Her dog ate a mouse who ate a Wilson Predator Rat and Mouse Killer Block. He ingested the mouse roughly 30 minutes ago. O: the dog vomited up part of a mouse 15 minutes ago R: rinse out the mouth, brush the teeth, dilute, and cleanse. Caller to notify the vet of this ingestion in the am. Dilute 4 6oz fluids and observe for signs/symptoms of bleeding (gum bleeding black stools, blood in urine or emesis)

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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.