Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5437

2. Registrant Information.

Registrant Reference Number: 4872673

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.

04-MAY-12

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

30-APR-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. 26904      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Ready To Use Home Pest Control

• Active Ingredient(s)
  • PERMETHRIN

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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. - In Home / Rés. - à l'int. 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 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

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Numbness
  • Symptom - Slurred speech

• General
  • Symptom - Fatigue

• Gastrointestinal System
  • Symptom - Salivating excessively

• Eye
  • Symptom - Watery eye
  • Specify - teary eye

• General
  • Symptom - Lightheadedness

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)

None

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Caller said that on Feb 15, she got sprayed by the product wilson home pest control. Walked into apt complex, a homeless man was spraying the product and sprayed it directly in to her face. She said that within minutes her her tongue went numb, she got teary eyed, and became light headed. Walked back to complex and one of the people that lives there said that this person does this occasionally. The caller said she started having slurred speech, salivating, and fatigue on second day, went to the Emergency Department. The maintenance guy that works at the complex said it was permethrin. Although she spoke with her landlord about which product the individual had in the bottle, it is still unclear what else she was exposed to. She has seen a doctor on two occasions and will see a neurologist. I transferred call to Customer Service to see how product was intended to be used. (age) yo GH no meds allergies: fake jewelry. Recommendations: Continue to see doctor. Call with questions/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.