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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4985

2. Registrant Information.

Registrant Reference Number: 5322266

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.

08-SEP-14

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

04-AUG-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. 17201      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Mosquito Fogging Insecticide

  • Active Ingredient(s)
    • PROPOXUR

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. - Out Home / Rés - à l'ext.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.

Other

2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Irritated eye

4. How long did the symptoms last?

Unknown / Inconnu

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

No

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)

Drift from the application site

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?

<=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.)

08/04/14 11:41 - The fogger went off into grand childs eyes. Caller is unable to verify the product as all of the instructions are in French. gh, nka, no meds R: Good that child had eyes rinsed immediately and is in bathtub being washed. Use soap and water on skin that was exposed to product and wash thoroughly. Irrigate eyes continuously for minimum of 15 minutes. After irrigation, have child close both eyes and place a cool damp cloth over them; rest the eyes for a minimum of 20 min. If eyes still feel irritated or like something is in them, seek medical attention for evaluation of the eyes. Fogger is readily absorbed through the skin. Watch for upset stomach - N/V/D and cramping, unexplained sweating, tearing, increased saliva, urinary frequency, increased secretions in lungs. If SXs develop, seek medical attention immediately. Call for any questions / concerns. Will follow up later. 08/04/14 13:08 - Child is ASX at this time w/ no further eye irritation. R: Continue to observe for SXs over next several hours. If now SXs within 12 hrs from time of exposure, probably will not develop any.

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.