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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5001

2. Registrant Information.

Registrant Reference Number: 5316421

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.

29-AUG-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

23-JUL-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. 21936      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant 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: Unknown / Inconnu

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Skin
    • Symptom - Rash
    • Symptom - Pruritus
    • Symptom - Irritated skin

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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 states that he bought a product called Wilson Ant Out. He does not have the product with him/in front of him. There are different kinds of Ant Out. This is a powder On the front it says it contains only Diatomaceous earth and a food grade attractant. He, thinking that the product was safe for humans had it all over his hands. As he was cleaning up his hand touched his armpit and he has this inflamed condition as a result. He is not calling for medical help as he has already seen a doctor. He has a question. He started doing research and some websites seem to indicate that this product has Carbaryl at 5% and this has been noted to be an insecticide and a potent one. One that can cause cancer. He wanted to know what the chemical components of the product he used are. He feels that his body has reacted to the Carbaryl. Even though the product he used did not indicate that this was an ingredient in it. It says underneath the name that it contains Diatomasceous Earth and food grade attractant. The other thing it says is Ant killer dust. Toe: July 12th and 13th, 14th A week and a few days later he has had this rash. He was exposed in the evening and the next morning he woke up with the rash. He has washed it and seen his doctor about it and his doctor prescribed a type of anti-inflammatory. He says it is a pill. He does not know what the pill is. GH, NKA, NO prior medication. Caller says that there is someone who will not come back to his home since this product has been used since this product is reported by this other person to have Carbaryl in it. Caller wants to obtain written information on product ingredients. R: 1. Reviewed that the Wilson AntOUt Ant Killer Dust is an irritant. Would need to wash off with soap and water and seek medical evaluation for persisting symptoms. It is not particularly toxic. Not expect to be a problem if someone got some diatomaceous earth in their mouth. 2. The Wilson AntOut Ant Killer Dust has a PCP code of P.C.P. Act Registration No.: 21936 Chemical acitve Name: Diatomaceous Earth. 3 The AntOut Product with the PCP# 26923 chemical name carbaryl.

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.