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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6654

2. Registrant Information.

Registrant Reference Number: 5133101

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: ALBERTA

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. 21936      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.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Edema
    • Symptom - Erythema
    • Symptom - Burning skin
    • Specify - Hot skin
    • Symptom - Irritated skin
  • General
    • Symptom - Pain
  • Skin
    • Symptom - Red skin

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

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?

>3 days <=1 wk / >3 jours <=1 sem

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.)

S. RN calls from (name) Campus, ED states pt in ED with c/o getting some Wilson AntOut Ant Killer Dust on a cut on her finger 5 days ago. Presents today with redness, swelling, pain, heat O. Redness, swelling, pain, heat Symptoms: Edema ErythemaFlushed Hot skin Irritationpain A. Acute adult dermal exposure to Wilson AntOut Ant Killer Dust, symptomatic. R. Reviewed with caller TOX available for consult. Reviewed Diatomaceous Earth non toxic. Caller request MSDS. MSDS faxed Caller declined f/u states MD will call back if any questions of concerns. CC/TE FAX fax has been successfully sent to pt Account: 118 Time: 7/29/2013 10:01:37 AM Sent with remote ID "SHC EMERG 25" Result: (0/3390/0) Successful Send Page record: 1 3 Elapsed time: 02:42 on channel 3 Therapies: No therapies recommended

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.