Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5067

2. Registrant Information.

Registrant Reference Number: 5238478

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.

10-MAR-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

21-FEB-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. 6944      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Warfarin, Rat and Mouse Killer - Pellets

• Active Ingredient(s)
  • WARFARIN (PRESENT IN FREE FORM OR AS SODIUM SALT)

---

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 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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Nausea

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 the walls of the house in the basement

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?

>1 yr / > 1 an

12. Time between exposure and onset of symptoms.

>6 mos / > 6 mois

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.)

02/21/14@09:57 Caller states that the product was put in walls of her basement about a year ago but began feeling sxs after Christmas. She states she feels the nausea and dizziness constantly, not just when she is in her basement or anywhere else in the home. She has not seen physician and would like to know if the product is still active and how to clean it up. Referred to customer service for product questions. Caller did not have the box anymore so I couldn't ask for a PCP #, referred to the product as the Wilson Warfarin Mouse killing seeds. Caller was advised that symptoms would not be expected to be related to exposure to this product. Since sxs are persisting this long, seek medical evaluation. 02/28/14 @ 09:25 she states she sought medical attention and was diagnosed with the Flu.

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.