Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5418

2. Registrant Information.

Registrant Reference Number: 4904317

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.

10-JUL-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-JUN-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. 14116      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Liquid AntOut

• Active Ingredient(s)
  • BORAX

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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.

Other

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Stomach cramps

• Eye
  • Symptom - Conjunctivitis
  • Symptom - Red eye

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

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

About 15 minutes ago, the caller's daughter got into the Wilson Liquid Ant Out in the car while the caller was driving home from the store. It doesn't appear as though any of the product is missing, and a smell of the product could not be detected on the child's breath or person. The caller suspected that the child may have gotten some of the product on her hands and then may have touched her face and eyes, as well as sucked on her fingers. The child's eyes appear slightly red and she is complaining of an upset stomach. GH NKA PCP#14116 R. Irrigate eye(s) for 20 30 minutes under a gentle stream of lukewarm water. Perform over a sink or a shower. Obtain large pitcher or glass, and allow water to pour onto the forehead or bridge of the nose and across the eyes from the inside to the outside . Do not hold eyelid(s) open, but slowly blink. Rest eye(s) after irrigating and no eye drops or ointments. Cool compress to closed eyes as needed. If symptoms continue or worsen over the next 1 to 2 hours eye exam Rinse mouth with water for about 20 minutes swish, gargle and spit. Brush teeth and tongue with tooth paste afterwards look inside mouth for swelling or blistering PC to CB in 2 hours for F/U. PC call back and spoke with father. The daughter was given a bath and something to eat. Her eyes were rinsed as well. She is now asymptomatic.

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.