Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5044

2. Registrant Information.

Registrant Reference Number: 5289808

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: NOVA SCOTIA

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. 27901      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut RTU

• Active Ingredient(s)
  • 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).

in bedroom

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: Male

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

• Gastrointestinal System
  • Symptom - Other
  • Specify - throat closing

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)

Contact with treated area

What was the activity? applied product in bedroom

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

Oral

11. What was the length of exposure?

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

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.)

Caller states that his fellow employee put some Wilson AntOut RTU in his bedroom and the next day woke up with a rash and his throat was closing up. Caller states that he was taken to the hospital treated and released but the doctors could not say what caused the reaction. The person exposed will have some follow up appointments. Caller did not want to give much information on the person exposed R. If the person is symptomatic, if symptoms persist or worsen, consult with PCP Case number provided and will provide MSDS if needed. Outcome unknown

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.