Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1613

2. Registrant Information.

Registrant Reference Number: 5360886

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.

Domestic Animal

4. Date registrant was first informed of the incident.

04-NOV-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

21-OCT-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. 30886      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Mouse Bait Station Kit Bait Block

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

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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. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

used out in the garage

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

Dog / Chien

3. Breed

border collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

35

kg

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 - Vomiting
  • Symptom - Diarrhea
  • Specify - soft stool
  • Symptom - Anorexia

• General
  • Symptom - Adipsia

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?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify ingested a poisoned rodent

17. Provide any additional details about the incident

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

The owner brought the dog to the clinic because he became symptomatic 12 h ago. The owners have the bait in the garage and don't think that Riley had direct access to the bait, but he does go into the garage. On 10/19, a mouse ran out of the garage and Riley may have ingested it. His signs developed on 10/20. The owners brought the bait station part of the kit and it fits this description. The owner was advised that because the amount was poorly consistent, the patient was considered to be at low risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. Significant ingestion can lead to coagulopathy. Relay toxicosis is not a high likelihood unless rodents are the pet's main diet. The dog would need to ingest 1 T of bait from the mouse's stomach to be at our level of concern

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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.