Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6716

2. Registrant Information.

Registrant Reference Number: 5152040

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.

04-OCT-13

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

01-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)

---

PMRA Registration No. 21850      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Malathion

• Active Ingredient(s)
  • MALATHION

---

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: 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?

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: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? product in garage leaking - children room above garage

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?

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

12. Time between exposure and onset of symptoms.

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

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: TC from mother. She states Wilson Malathion (Attach Spray) has leaked in the garage. She believes it may have happened Tuesday, as that is when she began to smell something bad. She says children have been presenting with illness this week, specifically vomiting. Caller says the children sleep above the garage. Caller's husband has been gone during the week. They were calling looking for cleaning instructions. Caller states children are not experiencing any other symptoms such as Salivation, Lacrimation, Urination, Defecation, and Gastrointestinal upse.t Philip No medical conditions No medications daily NKDA Christopher No medical conditions No medications daily NKDA Sarah No medical conditions No medications daily NKDA O: Vomiting (x3) A: Acute pediatric inhalation of Wilson Malathion (Attach Spray) SX (x4) R: Recommended seeking immediate medical attention, as malthion could be potentially dangerous. Will CB to F/U. 09/01/13 15:02 S: Placed call to number provided. Spoke with father. He states wife is at the Emergency Department with the children. Father wants to know how he should handle cleaning up the spill. I recommended contacting local fire and transferred to Customer Service. Will CB to speak with caller at a later time. O: A: R: 09/01/13 21:16 S: CB to number given, spoke with FOC, all 3 children are fine, symptoms resolved. Recommend to contact consumer services, Tuesday for clean up instructions. If odor is strong, stay somewhere else. O: A:

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: Male

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? product leaking in garage - children bedroom above garage

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?

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

12. Time between exposure and onset of symptoms.

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

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: TC from mother. She states Wilson Malathion (Attach Spray) has leaked in the garage. She believes it may have happened Tuesday, as that is when she began to smell something bad. She says children have been presenting with illness this week, specifically vomiting. Caller says the children sleep above the garage. Caller's husband has been gone during the week. They were calling looking for cleaning instructions. Caller states children are not experiencing any other symptoms such as Salivation, Lacrimation, Urination, Defecation, and Gastrointestinal upse.t Philip No medical conditions No medications daily NKDA Christopher No medical conditions No medications daily NKDA Sarah No medical conditions No medications daily NKDA O: Vomiting (x3) A: Acute pediatric inhalation of Wilson Malathion (Attach Spray) SX (x4) R: Recommended seeking immediate medical attention, as malthion could be potentially dangerous. Will CB to F/U. 09/01/13 15:02 S: Placed call to number provided. Spoke with father. He states wife is at the Emergency Department with the children. Father wants to know how he should handle cleaning up the spill. I recommended contacting local fire and transferred to Customer Service. Will CB to speak with caller at a later time. O: A: R: 09/01/13 21:16 S: CB to number given, spoke with FOC, all 3 children are fine, symptoms resolved. Recommend to contact consumer services, Tuesday for clean up instructions. If odor is strong, stay somewhere else. O: A:

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: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? product in garage leaking - children room above garage

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?

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

12. Time between exposure and onset of symptoms.

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

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: TC from mother. She states Wilson Malathion (Attach Spray) has leaked in the garage. She believes it may have happened Tuesday, as that is when she began to smell something bad. She says children have been presenting with illness this week, specifically vomiting. Caller says the children sleep above the garage. Caller's husband has been gone during the week. They were calling looking for cleaning instructions. Caller states children are not experiencing any other symptoms such as Salivation, Lacrimation, Urination, Defecation, and Gastrointestinal upse.t Philip No medical conditions No medications daily NKDA Christopher No medical conditions No medications daily NKDA Sarah No medical conditions No medications daily NKDA O: Vomiting (x3) A: Acute pediatric inhalation of Wilson Malathion (Attach Spray) SX (x4) R: Recommended seeking immediate medical attention, as malthion could be potentially dangerous. Will CB to F/U. 09/01/13 15:02 S: Placed call to number provided. Spoke with father. He states wife is at the Emergency Department with the children. Father wants to know how he should handle cleaning up the spill. I recommended contacting local fire and transferred to Customer Service. Will CB to speak with caller at a later time. O: A: R: 09/01/13 21:16 S: CB to number given, spoke with FOC, all 3 children are fine, symptoms resolved. Recommend to contact consumer services, Tuesday for clean up instructions. If odor is strong, stay somewhere else. O: A:

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.