Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5394

2. Registrant Information.

Registrant Reference Number: 4927801

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-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

20-JUL-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. 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?

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).

in garden

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

Labrador Retriever

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

13

7. Weight (provide a range if necessary )

90

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Trembling

• Gastrointestinal System
  • Symptom - Drooling

• 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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

Owner was outside with the dog at 4pm, while she was applying this in her gardens. She did not see the pet actually eat any of this or get into the bag. Pet vomited once at 5:30pm and started trembling and drooling about 45 minutes ago. Owner was advised that we can see GI upset at most with a small exposure and that they can manage the dog over the next hour to let the stomach settle. Call back if dog vomits anymore. Check to see if the dog could have been exposed to anything else. Spoke with owner on a call back. Owner confirmed pet was improving. She was, however, worried about interaction between it and the animals medications. Would not expect this. Owner mentioned Ben wobbled on his feet as he came into the room during the call, but this just happened once. She thinks he may just be tired. Advised her to call us back if it happens again/pet seems to actually have become ataxic.

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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.