Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4957

2. Registrant Information.

Registrant Reference Number: 5287220

Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.

Address: 1900 Minnesota Crt

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5N 3C9

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

12-JUN-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

29-MAY-14

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. 26679      PMRA Submission No.       EPA Registration No.

Product Name: HomeCare Bed Bug & Crawling Insect Killer Dust

  • Active Ingredient(s)
    • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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: 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).

unknown

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 - Sore throat

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 mos <=6 mos / > 2 mois < = 6 mois

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.)

Caller has been using the product liberally. The top of the callers soft pallet is tough. Caller has had a chronic sore throat and is trying to rule out if the product is causing callers symptoms. Caller takes copious amounts of water to relieve his throat irritation and takes chloraseptic to ease the irritation. Caller admits to being a smoker. Caller went to his ear, nose and throat doctor and they diagnosed him with irritation. Callers primary doctor had caller on two different antibiotics and had diagnosed caller with irritation also. gh, nka, meds: pain medications, tritratrol. R: Advised caller to ventilate the home until the dust odor is no longer there. Advised caller to always follow label instructions. Advised caller to wear PPE while cleaning his apartment. Advised caller to complete a steam inhalation treatment for relief. Advised caller to continue to follow his Doctors instructions if SX worsen or persist. Offered to call back to PC with any additional concerns. Caller declined PC to follow

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.