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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-5400
2. Registrant Information.
Registrant Reference Number: 4921205
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.
13-AUG-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
11-JUL-12Product 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)PMRA Registration No. 23300 PMRA Submission No. EPA Registration No.
Product Name: Green Earth Bio Mist Insect Killer
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
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).
unknownTo 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
- Gastrointestinal System
- Symptom - Tingling in mouth
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
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
Poisoning from ingestion of the pesticide
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Oral
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
Caller sprayed a herb with the product and than sprayed it with water. He made pasta out of it and noticed a bitter taste. He and his wife both ate some before realizing that it had been sprayed with the product. O Both tingling sensation in mouth R. Swish and spit. Brush teeth tongue Dilute with 2 6oz for children and 6 8 oz for adults If you experience difficulty swallowing, mouth, stomach pain or vomiting, seek medical attention PC will cb in 1 hour for follow up. Cb to caller to see how he and his wife are doing. He is doing fine and is not having any sx s anymore. His wife is psychologically stressed out about the exposure. She started to have a cool burning sensation in her stomach but it has gone away. She is having no sx s at this time. O Both ASX R CB to pc with any further questions or concerns.
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.
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Tingling in mouth
- Nervous and Muscular Systems
- Symptom - Anxiety
- Specify - stressed out about exposure
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
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)
Poisoning from ingestion of the pesticide
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Oral
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
Caller sprayed a herb with the product and than sprayed it with water. He made pasta out of it and noticed a bitter taste. He and his wife both ate some before realizing that it had been sprayed with the product. O Both tingling sensation in mouth R. Swish and spit. Brush teeth tongue Dilute with 2 6oz for children and 6 8 oz for adults If you experience difficulty swallowing, mouth, stomach pain or vomiting, seek medical attention PC will cb in 1 hour for follow up. Cb to caller to see how he and his wife are doing. He is doing fine and is not having any sx s anymore. His wife is psychologically stressed out about the exposure. She started to have a cool burning sensation in her stomach but it has gone away. She is having no sx s at this time. O Both ASX R CB to pc with any further questions or concerns.
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.
