Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6572

2. Registrant Information.

Registrant Reference Number: 4987277

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.

12-NOV-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 14058      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Mouse Treat

• Active Ingredient(s)
  • CHLOROPHACINONE

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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 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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Other
  • Specify - burning sensation inside

4. How long did the symptoms last?

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

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

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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 stating that 2 nights ago she touched the product to put it out with out wearing gloves. 1-2 hours later she started getting very sick. She vomited several times and everything inside was having a burning sensation. She drank a lot of water and the next day and she was fine. Her main complaint is that the product is not working to kill the mouse. GH5 bypasses, 2 leaking valves, knee replacements Meds:lots NKA Age:[age] Years Gender:Female O. vomiting everything inside her body has a burning sensation. SX Exposure: Wilson Mouse Treat R. Caller referred to customer service for her mouse problem to see if they can recommend another product to use. Cb to pc with any further questions or concerns. Therapies: Dilute/irrigate/wash(Performed), ingested lots of water

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.