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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1036

2. Registrant Information.

Registrant Reference Number: 4744089

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: ALBERTA

6. Date incident was first observed.

10-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. 28788      PMRA Submission No.       EPA Registration No.

Product Name: Wilson One Shot House and Garden Insect Killer

  • Active Ingredient(s)
    • D-PHENOTHRIN
    • TETRAMETHRIN

PMRA Registration No. 26192      PMRA Submission No.       EPA Registration No.

Product Name: OneShot Ant Roach and Crawling Insect Killer

  • Active Ingredient(s)
    • D-TRANS ALLETHRIN
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN

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

Product Name: Dr. Doom Pesticide

  • Active Ingredient(s)

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

Product Name: Home Defense Max RTU

  • Active Ingredient(s)

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).

Caller stated she used 3 4 separate products in her home 10 days ago. She sprayed approx 15 20 cans of the Wilson's and other products. The fumes are still present in the home. She and 2 others have been exposed to the product over that time, sx initially appeared the day after they were sprayed.

To be determined by Registrant

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

Yes

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

  • Respiratory System
    • Symptom - Nose bleed
  • Gastrointestinal System
    • Symptom - Anorexia
  • Skin
    • Symptom - Irritated skin
    • Symptom - Pain
  • Gastrointestinal System
    • Symptom - Irritated throat
  • Respiratory System
    • Symptom - Wheezing
    • Symptom - Respiratory distress
  • Skin
    • Symptom - Rash
    • Specify - bumps on wrist and arms

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

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

Unknown

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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 stated she used 3 4 separate products in her home 10 days ago (Wilson One Shot House andGarden Insect Killer, Wilson OneShot Ant Roach and Crawling Insect Killer, Dr.Doom Pesticide,Home Defense Max RTU) . She sprayed approx 15-20 cans of the Wilson's and other products. The fumes are still present in the home. She and 2 others have been exposed to the product over that time, sx initially appeared the day after they were sprayed. Mother: Tumors, Allergies :sulfa, prednisone, wasps, Grandson: GH, NKA Daughter: GH, NKA Outome: Grandson: "rash" and "swelling" on skin, Nose bleeds, fussy not wanting to eat and drink. Daughter: coughing, wheezing, headaches. Mother: Bumps on wrists and arms, Throat irritation, Mild resp distress, wheezing. Acute adult and pediatric inhalation and dermal exposure. Recomendation: Symptoms have persisted and worsened. Recommend to seek immediate medical attention for all three of them. Ventilate home. Contact customer service for best way to remove product of home. Otherwise keep out of home to prevent additional exposure, while fumes present. Caller stated she would be taking family to hospital today. CB scheduled tomorrow. Follow up call, no answer. LM with case and phone

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The information relayed to us from the consumer clearly identifies a misuse of the products in question through over application. 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.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Anorexia
  • Respiratory System
    • Symptom - Nose bleed
  • Skin
    • Symptom - Pain
    • Symptom - Irritated skin
    • Symptom - Rash
  • General
    • Symptom - Swelling
  • Blood
    • Symptom - Bleeding
    • Specify - nose bleed
  • Gastrointestinal System
    • Symptom - Loss of appetite
  • General
    • Symptom - Abnormal behaviour
    • Specify - fussy

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

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

Unknown

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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 stated she used 3 4 separate products in her home 10 days ago (Wilson One Shot House andGarden Insect Killer, Wilson OneShot Ant Roach and Crawling Insect Killer, Dr.Doom Pesticide,Home Defense Max RTU) . She sprayed approx 15-20 cans of the Wilson's and other products. The fumes are still present in the home. She and 2 others have been exposed to the product over that time, sx initially appeared the day after they were sprayed. Mother: Tumors, Allergies :sulfa, prednisone, wasps, Grandson: GH, NKA Daughter: GH, NKA Outome: Grandson: "rash" and "swelling" on skin, Nose bleeds, fussy not wanting to eat and drink. Daughter: coughing, wheezing, headaches. Mother: Bumps on wrists and arms, Throat irritation, Mild resp distress, wheezing. Acute adult and pediatric inhalation and dermal exposure. Recomendation: Symptoms have persisted and worsened. Recommend to seek immediate medical attention for all three of them. Ventilate home. Contact customer service for best way to remove product of home. Otherwise keep out of home to prevent additional exposure, while fumes present. Caller stated she would be taking family to hospital today. CB scheduled tomorrow. Follow up call, no answer. LM with case and phone

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.

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

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Anorexia
  • Respiratory System
    • Symptom - Nose bleed
  • Skin
    • Symptom - Pain
    • Symptom - Irritated skin
  • Respiratory System
    • Symptom - Coughing
    • Symptom - Wheezing
  • 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.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

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

Unknown

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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 stated she used 3 4 separate products in her home 10 days ago (Wilson One Shot House andGarden Insect Killer, Wilson OneShot Ant Roach and Crawling Insect Killer, Dr.Doom Pesticide,Home Defense Max RTU) . She sprayed approx 15-20 cans of the Wilson's and other products. The fumes are still present in the home. She and 2 others have been exposed to the product over that time, sx initially appeared the day after they were sprayed. Mother: Tumors, Allergies :sulfa, prednisone, wasps, Grandson: GH, NKA Daughter: GH, NKA Outome: Grandson: "rash" and "swelling" on skin, Nose bleeds, fussy not wanting to eat and drink. Daughter: coughing, wheezing, headaches. Mother: Bumps on wrists and arms, Throat irritation, Mild resp distress, wheezing. Acute adult and pediatric inhalation and dermal exposure. Recomendation: Symptoms have persisted and worsened. Recommend to seek immediate medical attention for all three of them. Ventilate home. Contact customer service for best way to remove product of home. Otherwise keep out of home to prevent additional exposure, while fumes present. Caller stated she would be taking family to hospital today. CB scheduled tomorrow. Follow up call, no answer. LM with case and phone

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.