Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6602

2. Registrant Information.

Registrant Reference Number: 5039169

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.

05-MAR-13

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

01-FEB-13

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. 29166      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Mouse and Rat Killer

  • Active Ingredient(s)
    • CELLULOSE (FROM POWDERED CORN COBS)

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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

unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1.5

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

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting

12. How long did the symptoms last?

<=30 min / <=30 min

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

Fully Recovered / Complètement rétabli

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

Telephone call from adult male regarding his dog who ingested approximately 6 Green Earth Mouse Following ingestion, the dog vomited once and he took him to the vet. At the vet, they gave him activated charcoal and Vitamin K. He just wants some additional information about the active ingredient that is in the Mouse and Rat Killer and why it could be harmful to his dog? Time of ingestion: 5 hours ago The dog is normally healthy, doesn't take any daily medications, and has no allergies O: vomited once, now asymptomatic A: Acute animal ingestion of Green Earth Mouse R: Per MSDS, this product contains Bromadiolone, which is a long acting anticoagulant. When ingested, it can cause an increased risk for internal bleeding which is why the vet gave him Vitamin K. Follow up with his vet as planned and call back with any additional questions or concerns. (Name) 02/06/13 10:47 S: Returned call to phone # provided. Spoke with ~ initial caller, regarding an error made in the initial information given regarding the Green Earth Mouse and Rat Killer which his dog ingested 5 days ago. Per the caller, the dog is doing fine now and is asymptomatic.


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.