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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6626
2. Registrant Information.
Registrant Reference Number: 5080061
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.
22-MAY-135. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
24-APR-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. 27492 PMRA Submission No. EPA Registration No.
Product Name: Wilson Riddex Bloks Rat and Mouse Bait
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
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).
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.
Other
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Shortness of breath
- Symptom - Coughing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? rodenticide applied in the attic of the house
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.
Respiratory
11. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>1 mo <=2 mos / > 1 mois < = 2 mois
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.)
S. Caller stated she put down \fs23 Wilson\ ae Riddex\ ae Bloks Rat Mouse Bait 4 months ago in the attic and her and her family have been have mild respitory distress ever since. caller is pregnant, transferred to SPI The family is in good health with no meds or allergies O. shortness of breath, Coughing up phelm A. Acute, adult/pediatric, inhaltion, R. Transferred to SPI Patient #1 Therapies: Unknown if therapy provided Patient #2 Therapies: Unknown if therapy provided Patient #3 Therapies: Unknown if therapy provided S: Spoke with caller no ingestion. She had them placed in the attic and is concerned that rat's may not have finished them. Their symptoms started shortly after placing them in the attic a couple months ago. She has already been to PCP regarding the sx. O: Shortness of breath, coughing up phlegm A: Chronic adult possible inhalation of Wilson Riddex Bloks Rat and Mouse Bait, sx unlikely related R: Would not expect sx from inhalation of product. Sx come from repeated ingestions or large acute ingestions. Sx include bruising and bleeding. Would not expect respiratory sx from ingestion of product. If sx persistent would recommend seeking medical attention CB with further quesitons/concerns cc/ap
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.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
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 - Shortness of breath
- Symptom - Coughing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Rodenticide applied in the attic
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.
Respiratory
11. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>1 mo <=2 mos / > 1 mois < = 2 mois
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.)
S. Caller stated she put down \fs23 Wilson\ae Riddex\ae Bloks Rat Mouse Bait 4 months ago in the attic and her and her family have been have mild respitory distress ever since. caller is pregnant, transferred to SPI The family is in good health with no meds or allergies O. shortness of breath, Coughing up phelm A. Acute, adult/pediatric, inhaltion, R. Transferred to SPI Patient #1 Therapies: Unknown if therapy provided Patient #2 Therapies: Unknown if therapy provided Patient #3 Therapies: Unknown if therapy provided S: Spoke with caller no ingestion. She had them placed in the attic and is concerned that rat's may not have finished them. Their symptoms started shortly after placing them in the attic a couple months ago. She has already been to PCP regarding the sx. O: Shortness of breath, coughing up phlegm A: Chronic adult possible inhalation of Wilson Riddex Bloks Rat and Mouse Bait, sx unlikely related R: Would not expect sx from inhalation of product. Sx come from repeated ingestions or large acute ingestions. Sx include bruising and bleeding. Would not expect respiratory sx from ingestion of product. If sx persistent would recommend seeking medical attention CB with further quesitons/concerns cc/ap
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.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Male
Age: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Coughing
- Symptom - Shortness of breath
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Roddenticide applied in the attic
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.
Respiratory
11. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>1 mo <=2 mos / > 1 mois < = 2 mois
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.)
S. Caller stated she put down \fs23 Wilson\ae Riddex\ae Bloks Rat Mouse Bait 4 months ago in the attic and her and her family have been have mild respitory distress ever since. caller is pregnant, transferred to SPI The family is in good health with no meds or allergies O. shortness of breath, Coughing up phelm A. Acute, adult/pediatric, inhaltion, R. Transferred to SPI Patient #1 Therapies: Unknown if therapy provided Patient #2 Therapies: Unknown if therapy provided Patient #3 Therapies: Unknown if therapy provided S: Spoke with caller no ingestion. She had them placed in the attic and is concerned that rat's may not have finished them. Their symptoms started shortly after placing them in the attic a couple months ago. She has already been to PCP regarding the sx. O: Shortness of breath, coughing up phlegm A: Chronic adult possible inhalation of Wilson Riddex Bloks Rat and Mouse Bait, sx unlikely related R: Would not expect sx from inhalation of product. Sx come from repeated ingestions or large acute ingestions. Sx include bruising and bleeding. Would not expect respiratory sx from ingestion of product. If sx persistent would recommend seeking medical attention CB with further quesitons/concerns cc/ap
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.
