Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6627

2. Registrant Information.

Registrant Reference Number: 5078289

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.

10-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

20-APR-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. 28353      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat and Mouse Killer Pellets Place Pack

• Active Ingredient(s)
  • DIFETHIALONE

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Wheaten Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

40

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• General
  • Symptom - Other
  • Specify - Muddy Muscous Membranes

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The owner put 120g of the bait into a mouse hold 3 days ago. Today she just noticed that the area was disturbed and some of the pellets were scattered over the floor. The dog ingested a WCS 120g. Today about 1.5 hours ago the owner noticed that the dog has muddy mucus membranes. The owner was advised that the concern with this exposure is for internal bleeding. The owner should take the dog into the clinic tonight and have the DVM call back to continue the case. On April 22, 2013 Called the owner to update the case. The owner took the dog to an Er facility on Saturday evening, and 2 clotting test were administered. The tests was normal. The DVM thought that Prissy's gums were normal in color per the owner- the owner believes she herself over reacted. The dog has a check up at the reg. vet tomorrow. Per Dr., if the clotting test came back normal on Saturday, then the pet is normal.

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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.