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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6595
2. Registrant Information.
Registrant Reference Number: 5067718
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.
09-APR-135. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
31-MAR-13Product 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. 7386 PMRA Submission No. EPA Registration No.
Product Name: Green Earth Dormant Spray Kit
- Active Ingredient(s)
- LIME SULPHUR OR CALCIUM POLYSULPHIDE
PMRA Registration No. 21348 PMRA Submission No. EPA Registration No.
Product Name: Green Earth Horticultural Oil Insect Spray
- Active Ingredient(s)
- MINERAL OIL
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. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
unknownTo 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
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- General
- Symptom - Licking
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?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owner applied this product about 1-2 wks ago per label instructions. The dog was allowed into the yard the next day, but was observed licking the tree yesterday. Last pm, the dog started vomiting. The dog has continued to vomit today after each time she drinks water. Caller was advised that because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is moderate risk that those signs will be life-threatening. If this dog licked the product directly from the bottle then these signs would be expected but if the product has been exposed to the elements for over a week then it is unlikely that this product caused the clinical signs.
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 Interviews. 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.
