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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-6710
2. Registrant Information.
Registrant Reference Number: 5159712
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.
Human
4. Date registrant was first informed of the incident.
18-OCT-135. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
15-SEP-13Product 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)PMRA Registration No. 26923 PMRA Submission No. EPA Registration No.
Product Name: Wilson Ant Killer Dust
- Active Ingredient(s)
- CARBARYL
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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?
Unknown
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: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Cardiovascular System
- Symptom - Chest tightness
- Specify - Tightness in chest
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? vacuumed up product and in haled product
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Respiratory
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 states that he vaccumed up some Wilson Ant Killer Dust about 1 hour ago. Caller and his wife now feel tightness in they're chest and have breathes fresh air. (name): GH, NKDA, NOPPI Wife: GH, NKDA, NOPPI SX: Tightness Symptoms: Other A. Acute adult inhalation exposure to Wilson Ant Killer Dust, SX Exposure: Wilson Ant Killer Dust R. Breath Fresh Air for 15 20 minutes Call back with any questions or concerns Therapies: Fresh air(Both),
To be determined by Registrant
14. Severity classification.
Minor
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.
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Cardiovascular System
- Symptom - Chest tightness
- Specify - Tightness in chest
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? product was vacuumed and inhaled product
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Respiratory
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 states that he vaccumed up some Wilson Ant Killer Dust about 1 hour ago. caller and his wife now feel tightness in they're chest and have breathes fresh air. (name): GH, NKDA, NOPPI Wife: GH, NKDA, NOPPI Caller: Dave Patient Name: Dave Age:unknown adult Gender:Male O. SX: Tightness Symptoms: Other A. Acute adult inhalation exposure to Wilson Ant Killer Dust, SX Exposure: Wilson Ant Killer Dust R. Breath Fresh Air for 15 20 minutes Call back with any questions or concerns Therapies: Fresh air(Both),
To be determined by Registrant
14. Severity classification.
Minor
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.
