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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5450

2. Registrant Information.

Registrant Reference Number: 4757718

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.

09-NOV-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-OCT-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. 28352      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat and Mouse Killer Bloks

  • Active Ingredient(s)
    • DIFETHIALONE

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).

he had previously placed 2 blocks in the fan above the stove.

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.

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

  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • 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

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.)

The caller was cooking bacon and turned on the fan above his stove. After eating, he noticed that there were green crumbs sprinkled around the pan. He realized that some pieces from the 2 bars of Wilson Predator Rat Mouse Killer Bloks that he had previously placed in the fan. He thinks that some of the may have possibly fallen into his bacon as it was cooking. Currently the caller feels fine, he just began felling a little "light headed" after eating about 20 30 minutes ago. Since the exposure the caller has had a Pepsi and a cigarette. The caller stated that both bars bars are still in the fan, and only the amount of a "cigarette ash" may have fallen. Health Hx: Hepatitis C Chronic Fatigue Disorder had an operation on his cervical spine 2 months ago Hiatus Hernia fatty liver handicapped Meds: Prevacid Tylenol KNA to meds. Patien has hay fever and allergic to dust Caller was recommended to rinse mouth with water ,brush teeth, dilution with milk or water, watch for any abnormal bleeding over the next 24hrs. If symptoms develop to call back, and consult with physician. PC to CB in 48hrs. Left message on voice mail to call back, no return call

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.