Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-6017

2. Registrant Information.

Registrant Reference Number: 5372520

Registrant Name (Full Legal Name no abbreviations): Sure-Gro IP 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.

05-DEC-14

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

27-NOV-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. 28352      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat & Mouse Killer Bloks

• Active Ingredient(s)
  • DIFETHIALONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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: Male

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

3. List all symptoms, using the selections below.

System

• Reproductive System
  • Symptom - Other
  • Specify - Genital Shrinkage

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Symptom - Numbness
  • Symptom - Disorientation

• General
  • Symptom - Lethargy

• Eye
  • Symptom - Other
  • Specify - flashes of light in his vision for 4 months

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 believes he was poisoned by this product. TOE: 1 year ago. Says it was put in his coffee. Caller swallowed about a tsp of the coffee. He experienced confusion, dizziness, disorientation, nausea, lethargy and flashes of light in his vision for 4 months. States bitter taste on tongue lasted for 3 weeks. Right leg became numb for 2 months, states he had genital shrinkage for 6 days. Today he is ASX. States he has gone to physicians and psychiatrists. Caller wants to speak with a toxicologist. GH; no meds; NKA. Reviewed with caller health symptoms as above with toxicologist. Caller asking if this product would cause genital shrinkage that lasted for 6 days, 1 year ago. Caller states he thinks someone put some in his coffee. Symptoms described are not consistent with exposure to product provided. Recommend seeking medical care of any ongoing symptoms. Caller to call if further concerns or questions

To be determined by Registrant

14. Severity classification.

Moderate

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.