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: 2013-6634

2. Registrant Information.

Registrant Reference Number: 5104013

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. 9802      PMRA Submission No.       EPA Registration No.


  • 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).

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: Male

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

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • General
    • Symptom - Lightheadedness

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)

Contact with treated area

What was the activity? Malathion stored in basement - product split open when moved

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 <=2 hrs / >30 min <=2 h

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 found the spilt product in the basement of his workplace. Caller wants to know how to clean the product up properly. Caller said that the smell is so strong that every time he goes near the product he becomes light headed. O: A: R: Transferred caller to a SPI to contact 911 for hazmat clean up and for potential multiple exposures. S: Call transferred PIP Caller states 30 mins ago he was rearranging stuff in worksite store basement, 250 ml container of Wilson 50% Malathion Liquid Insecticide Miticide spilled from bottom when he picked up container and got onto concrete floor. He states the smell was strong, he used kerchief over face, poured water over floor to dilute product, opened large door to air out and put product outside in trash. Door connecting basement to store is closed and does not smell odor upstairs in store. Recs? SX caller felt lightheaded while he was in area, states this has resolved and he feels better. Diluted with water. NKDA GH NO MEDS O: SX felt light headed A: Adult acute occupational exposure to fumes from Wilston 50% Malathion Liquid InsecticideMiticide SX resolved. R: continue ventilation of basement. call 911/nonemergency to come assess site, HazMat assist clean up. Caller to go outside and get fresh air x 1 hour slow deep breaths, sips of fluids. call back for sx or questions, Haz Mat to call if need product information/MSDS. follow later. (name) 06/06/13 14:08 S: PC CB no answer. Left message requesting CB O: A: R: PC to FU. (name)06/06/13 16:31 S: PC CB the sx resolved. O: A: R:

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.