Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5043

2. Registrant Information.

Registrant Reference Number: 5289810

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.

14-JUL-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

03-JUN-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. 26201      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Jet Foam Wasp & Hornet Killer

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

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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: 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: Female

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Bloody vomit

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.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

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

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.)

06/03/14 - 7:54 -Caller states that she was spraying some Wilson Jet Foam Wasp Hornet Killer last night and thinks she might have inhaled the product because she woke up having dizzy spells and vomited once and it blood in it. Caller said that she actually had a dizzy spell while still laying down. Caller does take 8 different medications daily but states that they have never made her dizzy. NKA - Smoker 1 1/2 a day. Caller thinks she was spraying too close when she used product yesterday around 1900-2000 - duration 5-10 mins - she was spraying on balcony/ceiling. She felt dizzy this morning when she was turning in bed and continued to feel dizzy when she got out of bed, wonders if it's related to product use. As we speak she states she has eaten a banana and now is feeling better. She is diabetic but does not check her blood sugar at home. She also spit and had some red color in spit, but she had eaten blue berries so not sure if that what caused color. Recs? Recommendation: protein snack, have someone check on her over next couple hours to make sure she is doing OK (no one can come over), ER evaluation if SX do not resolve. 06/03/14 - 9:30 (follow up call) caller States she fell down, still feeling dizzy, someone is coming to pick her up to take her to ER. Not calling 911. Will go to (name) Memorial 06/03/14 - 13:00 unable to reach the caller. 06/04/14 - 7:25 caller states he has a problem that she gets "dizzy spells" and it will happen in the future. States it is not related to the product at all.

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.