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: 2013-6661

2. Registrant Information.

Registrant Reference Number: 5128368

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. 21111      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Insecticidal Soap

  • 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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Rash

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?

>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: Caller applied the product to her plants and now has a rash on her neck, stomach, back and arm pits. Caller was applying the product for 30 minutes. Caller got her sleeves wet with the product and then went into shower. Callers symptoms started the day after the use of the product. Callers rash started last Wednesday. Caller did go to the Doctor. Doctor is uncertain what the rash is from and is able to confirm that caller doesn't have shingles. Doctor gave caller prednisone and an antihistamine. Caller is unable to verify EPA number. gh, latex, bp meds, lipitor , SX R: Caller advised that she has an additional Doctors appointment on Monday. Advised caller of case number and PC number. Advised caller to bring product into her Doctors office with her and her Doctor is welcome to contact PC as needed. Offered to call back to PC with any additional concerns PC to follow. 07/22/13 11:18 S: TC to listed # left message requesting medical outcome. Left PC number and case number. PC to follow 1X O: A: R: 07/22/13 12:05 S: Caller returned PC call. Caller went to the Doctor and was diagnosed with Poison Oak. Caller is now treating for Poison Oak with her Doctor. Offered to call back to PC with any additional concerns.

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.