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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6631

2. Registrant Information.

Registrant Reference Number: 5102333

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 29054      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Weed and Garden Grass Killer

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Foreign body sensation in eye

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 stated she was using Green Earth Weed Grass Killer RTU and got a drop in her left eye about 15 minutes ago. She briefly rinsed GH, blood pressure meds no allergies O. fells like something in eye A. acute, adult ocular exposure, R. Advised caller to get in shower and have water fall onto forehead and have a gentle stream of water flow into the eye and blink respeatly for 1520 minutes then apply a warm compress for 1520 minutes. pc to followup 06/03/13 17:57 S. spoke to caller, she just got out of shower, pc to follow up R. 06/03/13 20:03 S. Spoke to caller and she stated her eye feels better but it still feels like soemthing is in her eye. Advised caller to go ahead and be seen by a doctor tonight. PC to follow up Caller: R. 06/04/13 14:58 S: Cb to see how her eye is doing. Unable to speak with anyone. PC left a VM with case number and number to company. Cb to pc. PC will folow up tomorrow if not cb. R: PC 06/05/13 15:20 S. attempted to call patient, left message, pc to follow up R. Therapies: Dilute/irrigate/wash(Recommended), PC 06/05/13 19:37 S. Spoke to caller and she stated she was givin antibiotics last night and will be going to the eye dr tomorrow. PC to follow up Therapies: Dilute/irrigate/wash(Recommended), PC 06/06/13 15:26 S. left vm, pc to follow up tomorrow R. Therapies: Dilute/irrigate/wash(Recommended), PC 06/07/13 15:08 S. left voicemail, closing case

To be determined by Registrant

14. Severity classification.


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.