Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6606

2. Registrant Information.

Registrant Reference Number: 5028334

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.

05-FEB-13

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

11-JAN-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)

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PMRA Registration No. 15284      PMRA Submission No.       EPA Registration No.

Product Name: Riddex, Rat and Mouse Killer Pellets

• Active Ingredient(s)
  • CHLOROPHACINONE

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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).

unknown

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: Male

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

4. How long did the symptoms last?

>1 mo and <= 2mos / >1 mois et < = 2mois

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)

Other

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.

Unknown / Inconnu

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 states that he has been using the Wilson Riddex Rat and Mouse Killer Pellets Active ingredient n/a per caller. Caller only coughs when he is in his kitchen, attributing his cough to dermal exposure, to wilson riddex rat and mouse killer pellets. Caller states that he spoke with someone in customer service division of the company back in September when he initially purchased the product at which time he was informed that the product was toxic to humans, and that it would take approximately 2 weeks for the product to be effective. States that he experienced a dermal exposure when a mouse ran under his bed and dropped pellets he than awoke and stepped on the pellets. Cough x 2 months GH; NKA; no regular medications. Due to persisting cough x 2 months. Seek medical evaluation, case # provided encouraged to have PMD call with any questions or concerns. Reviewed with caller . During follow up call the caller stated that he went to PCP to get reated, evaluated, and released. No meds given

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.