Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6723

2. Registrant Information.

Registrant Reference Number: 5139371

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.

17-SEP-13

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-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. 28353      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat and Mouse Killer

• Active Ingredient(s)
  • DIFETHIALONE

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

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

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Dizziness

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

The owner says this cat is out all day and then comes in the house at night. The pet is very proficient at catching mice, she usually leaves 1-3 per day on the steps to the house for the owner. The owner found a mouse the pet had left for them Monday morning (08/05), the difference with this mouse is the owner says it was fat and bloated. The pet started to behave abnormally Monday night, she was hiding, not wanting to interact with the owner, not eating and very lethargic. The pet's condition has not improved, she started with diarrhea the next day that has progressed to being more severe. The owner has been taking the pet into the DVM on/off all week, they have done many diagnostics and are not finding anything significant. The owner is concerned with a relay toxicity. The caller was advised that relay toxicity is unlikely unless these dead mice are main source of nutrition for the cat.

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To be determined by Registrant

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

Minor

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.