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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6715

2. Registrant Information.

Registrant Reference Number: 5154194

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.

Domestic Animal

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. 27124      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Home Care Ant, Roach and Crawling Dust

  • Active Ingredient(s)

PMRA Registration No. 26720      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth HomeCare Flying and Crawling Insect Killer

  • 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: 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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Diarrhea
  • General
    • Symptom - Drowsiness
    • Symptom - Lethargy
    • Symptom - Malaise
    • Specify - been sick

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

S: Caller used the product in home 4 days ago,caller sates that his dog got sick the day after using the product. Caller states that his dog has had diarrhea and been sick every since he used both products. Caller states that he took the dog to the vet and the vet did nothing for the dog. TOE4 days ago Gh,NO MEDS,NKA O: SXdiarrhea lethargic anorexia A: acute,animal,Green Earth HomeCare Ant, Roach Crawling Dust,Green Earth HomeCare Flying Crawling Insect Killer,SX R: Transferred NAPCC. Case# Caller got disconnected during transfer. Tried calling owner back. Got recording stating that number cannot receive incoming calls. No option to leave message. On Sept 6, 2013 contact with caller was made and caller was informed that based on the information provided the patient was considered not to be at risk of developing further clinical signs. If signs develop, there is no risk that those signs will be life-threatening.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. 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.