Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0879

2. Registrant Information.

Registrant Reference Number: 5072037

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.

15-MAY-13

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

09-APR-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. 27492      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Riddex bloks Rat and Mouse Bait

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)

---

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: Pub. Area - Indoor/Zone publique - int

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest tightness

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? Rodenticide was used at the school

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.

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest pain

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Nervous and Muscular Systems
  • Symptom - Headache

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Eye
  • Symptom - Irritated eye
  • Symptom - Pain

• Cardiovascular System
  • Symptom - Chest pain

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? Rodenticide was used at the school

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 is a custodian at a elementary school and is concerned because teachers and children have been having burning sensation in their eyes, tightness in their chest and headaches. Caller is trying to rule out what could be causing the teachers and children to be having the reaction. Caller states 5 students went home last week and 2 more yesterday One teacher got cortisone shot for sxs specialist is coming up to school tomorrow to evaluate air. Asking if this product would produce sxs if inhaled? This was placed last fall and then beginning of march and the end of march These have been placed under shelves , between freezers and walls Not in reach of children. R: Would not relate sxs to product. This is a long acting anticoagulant. Medical evaluation as indicated for sxs cc/gm

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.