Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5432

2. Registrant Information.

Registrant Reference Number: 4881071

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.

11-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-MAY-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. 7386      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Lime Sulphur

• Active Ingredient(s)
  • LIME SULPHUR OR CALCIUM POLYSULPHIDE

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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).

unknown

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Discolouration
  • Specify - hands are white
  • Symptom - Discolouration
  • Specify - nails are yellow

• Nervous and Muscular Systems
  • Symptom - Anxiety

4. How long did the symptoms last?

Unknown / Inconnu

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Chemical resistant gloves

10. Route(s) of exposure.

Skin

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 was using the product and wearing fabric gloves. The product soaked through the gloves on to his hands. He had the product on him for about 30 minutes. Afterwards he washed for 15 20 minutes in the shower. Gh No Med NKA . O. hand white, nails yellows, discomfort (anxiety). R. Gently rinse skin well under gentle stream of comfortable temperature water for 15 20 minutes. Wash contaminated skin and hair 3 times with soap and water. May also wash with mild soap. The product can cause burns/blisters any other symptoms seek medical attention. PC will call back in a couple of hours for follow up. CB to caller to see how he is doing. He is doing better and his fingers are slowly coming back to normal. His skin feels tight, but is going back to normal. Final outcome unknown, further call backs declined.

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.