Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6714

2. Registrant Information.

Registrant Reference Number: 5156495

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.

11-OCT-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

09-SEP-13

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.

Active(s)

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PMRA Registration No. 28788      PMRA Submission No.       EPA Registration No.

Product Name: Wilson One Shot House and Garden Insect Killer

• Active Ingredient(s)
  • D-PHENOTHRIN
  • TETRAMETHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. maison

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: Female

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

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Other
  • Specify - sensation of film like coating on top of mouth
  • Symptom - Chemical taste in mouth
  • Specify - Bad taste in mouth

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? drank from a glass where product was sprayed near

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.

Oral

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 her boyfriend sprayed the product near the dishes, caller states she went and drank some water out of one of the cups that was sprayed. After she drank some water from the cup she noticed a weird taste in her mouth. Caller states that she has a film like coating in the top of her mouth. Caller states that she rinsed her mouth out but still has the weird taste/feeling in her mouth. TOE30 min ago GH,MEDSBirth Control,NKA O: SXirritation (film like coating) A: acute,adult,ingestion,Wilson One Shot House Garden Insect Killer R: Dilute with 68 oz of water If you experience difficulty swallowing, mouth, stomach pain or vomiting, seek medical attention Declined CB CB to PC with any further questions or concerns

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.