Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5013

2. Registrant Information.

Registrant Reference Number: 5198836

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.

Domestic Animal

4. Date registrant was first informed of the incident.

13-JAN-14

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

01-DEC-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)

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PMRA Registration No. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat and Mouse Bait

• Active Ingredient(s)
  • BROMADIOLONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic Medium hair

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2.5

7. Weight (provide a range if necessary )

12

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Lethargy

• Skin
  • Symptom - Hair loss
  • Specify - Alopecia

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

As per the owner, the cat may have gotten into the bait yesterday or before, and her mother told her about it today. She does not have the package with her, and drove 1.5 horus to the vet clinic, who wanted to charge her a good deal of money to treat. Her cat is lethargic, not eating, and losing hair. Owner calling to obtain help. She does not have information about the rodenticide and she is not in the same town as the vet clinic, which is an hour away. She wants treatment advice for what to do at home for her cat. Advised owner to return to the vet and have the vet give us a call back to continue the consultation with the cat's vitals. It is unlikely we will be able to treat her pet at home, as we cannot do anything at home with cats that is safe for them, and it may have been a day (or more) since the ingestion. While her pet is at the vet, she can run to a local hardware store and find the box of the produce she purchased and obtain the PCP number or a list of active ingredients and concentrations. Have the vet call to continue the consultation

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. 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.