Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6721

2. Registrant Information.

Registrant Reference Number: 5144224

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.

20-SEP-13

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

18-AUG-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. 25300      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Total WipeOut

• Active Ingredient(s)
  • GLUFOSINATE AMMONIUM

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Irritated throat

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

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.

Skin

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 / <=30 min

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 stated her son was briefly alone with Wilson Total WipeOut (ReadytoUse) (PCP 25300) for about 1 minute 20 minutes ago. She saw the product around his mouth and hands, After, he had a bath and drank water Gh, no meds no allergies O. vomiting, touching mouth Symptoms: Vomiting Oral irritation A. acute, pediatric, ingestion exposure, R. Advised caller to wash hands and face with warm soapy water for 10 minutes, brush teeth and provide something to drink. Per Spi, they should go to the ED now. pc to follow up Therapies: Dilute/irrigate/wash(Recommended), 08/18/13 14:35 S: call from CSPI at (province) Canada PC pt is currently in the HCF. local PC was contacted by HCF caller requesting MSDS for the product faxed the MSDS to local PC fax was transmitted successfully. nh O: S: TC to (province) PC at O: product was wilson total wipe out but contained citric acid per the label that was brought to ER child vomited x 1 and was asx after that A: acute pediatric oral exposure sxs resolved

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.