Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5389

2. Registrant Information.

Registrant Reference Number: 4935709

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: UNKNOWN

6. Date incident was first observed.

21-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. 17482      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Bordo Spray

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS TRIBASIC COPPER SULPHATE)

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

80

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Ataxia

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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

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

Owner applied this diluted product to a tree in her yard 3 days ago. The dog had access to the yard since the product was used and it possible he ingested some grass that may have been coated with the product. The caller was advised that this product can be corrosive if ingested undiluted, and often will stain the tongue and oral cavity a blue-green color. Risks are for vomiting, diarrhea, GI signs with blood, and oral ulcerations. Sudden onset of ataxia is not expected. The dog should be seen by the DVM. Have the DVM call for information. Caller was hesitant to take the case number and then disconnected prior to obtaining the whole case number and call back number.

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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.