Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6571

2. Registrant Information.

Registrant Reference Number: 4987071

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.

Domestic Animal

4. Date registrant was first informed of the incident.

12-NOV-12

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

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

Product Name: Wilson Predator Rat and Mouse Killer Blok

• Active Ingredient(s)
  • DIFETHIALONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu

4. Number of animals affected

1

5. Sex

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

9

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Owner placed two blocks two days ago and found the next day that both blocks were missing. Owner did set out an additional two blocks last night but they were attached to the area were they were placed. They appeared chewed but they are not in reach for the dog. Owner found three piles of vomitus. There is some evidence of rodenticide in vomitus. The owner was advised that this agent is an anticoagulant rodenticide. With this exposure, we can see coagulopathy. Initial clinical signs are vague: anorexia, lethargy, exercise intolerance. Signs progress hemorrhage into chest (causing dysnpea), abdomen, or joint (causing lameness). May see bruising. On October 26, 2012, Owner called back to update the case. Owner was told by her DVM that the PT would not be necessary at 48-72 hours post last dose. Owner was told that the test was expensive and a difficult process. Owner thought the clinic told her they would have to get comparable's from another dog. Per the Dr. PT testing is a pretty common practice and generally involves obtaining the blood in a special tube and sending off to a lab, however there might be some differences in Canada. Recommended owner have clinic call to discuss PT test if they have any questions. We recommend the PT as a safety precaution as this rodenticide is a second generation anticoagulant. Most dogs do fine with a 30 day dose of vitamin K1, however again this is a precaution. [Name] (the dog) was given an injection at the clinic as well as placed on Vitamin K1 for 30 days

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. 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.