Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4972

2. Registrant Information.

Registrant Reference Number: 5336712

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

09-OCT-14

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

01-SEP-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)

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PMRA Registration No. 23300      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Bio-Mist Insect Killer

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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: Other / Autre

Préciser le type: on person

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

on husbands testicles

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burning skin
  • Symptom - Irritated skin
  • Symptom - Tingling skin

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)

Application

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

11. What was the length of exposure?

<=15 min / <=15 min

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.)

09/01/14 21:55 Caller stated that they put solution into spray bottle, no label on bottle. (age) yo immuno suppressed, transplant patient, cells that make insulin ( islets), /Allergy to anti inflammatory meds. Wife of patient who mistakenly sprayed this product on her husband's testicles she thought it was a health care product. The product had been placed in a spray bottle very similar to the bottle containing a health care product. Caller suggest "that the company should put the insecticide in a spray bottle so this type of mix up won't happen". TOE: 5mins ago Suggested to caller to get her husband in the shower. Caller is unable to get her husband to a shower or a bathtub, he uses a wheelchair. Recommend to scoot him forward in the chair and put a basin on the floor underneath his testicles. Need to rinse with fresh water 15-20mins, soap and rinse x 3 Therapies: Dilute/irrigate/wash(Recommended), Fresh water running over the area 15-20mins, soap and rinse x 3. 09/01/14 23:41 CB to number given, spoke with the wife. She had also call a "poison center" and they advised that she take him to ER. So they did. She said he is feeling a little better, now has a tingling sensation. She did rinse as recommended before going in.

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.