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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5445

2. Registrant Information.

Registrant Reference Number: 4782552

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.

16-JAN-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

08-DEC-11

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)

PMRA Registration No. 26719      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth HomeCare Ant and Crawling Insect Killer

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN
    • 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: Pub. Area - Indoor/Zone publique - int

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller states that the elementary school officials allowed a classroom full of (number) th graders to remain in the room when "someone" sprayed Green Earth HomeCare Ant and Crawling Insect Killer and several other unknown products in the classroom.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

  • Nervous and Muscular Systems
    • Symptom - Headache

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a parent of a female 5th grader. Caller states that the elementary school officials allowed a classroom full of 5th graders to remain in the room when "someone" sprayed Green Earth HomeCare Ant and Crawling Insect Killer and several other unknown products in the classroom. Caller does not know the name of the other products. TOE: Yesterday. 12 07 11 Caller states the school did not tell the parents they were going to or did this. At least 30 patients. Caller states the kids were complaining of head aches. Caller gave her daughter tylenol and her head ached resolved last night. Caller was advised about signs and symptoms and what to look for with inhalation exposure to product. Symptoms have resolved for caller's daughter. Pts have since left the classroom and received fresh air.

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.