Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1622

2. Registrant Information.

Registrant Reference Number: 5379540

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: ONTARIO

6. Date incident was first observed.

30-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. 7386      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Lime Sulphur

• Active Ingredient(s)
  • LIME SULPHUR OR CALCIUM POLYSULPHIDE

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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: Animal / Usage sur un animal domestique

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

applied the product to her dog, per vets instructions

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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

• Skin
  • Symptom - Burning skin
  • Symptom - Erythema

4. How long did the symptoms last?

Unknown / Inconnu

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

No

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.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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 was treating her dog with this product as instructed by the dog's Vet. The dog shook and it splashed on the caller face, on the sides of her nose under her eyes. O. Burning sensation, sides of nose, under the eyes. Caller was recommended to apply comfortable temperature of water. Don't put anything topical on your face until the burning sensation stops. Can try cool compress for 20mins. Therapies: Dilute/irrigate/wash(Recommended), Dilute with fresh running water, 20mins. During a follow up call 1 hour later, the caller's face is feeling a lot better but still has a slight burning sensation. She hasn't tried the cool compress yet and will try that now. Face feels very tight/dry. Caller was recommended that if skin cracks, bleeds or blisters seek medical eval. Can apply Neosporin or like product.

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.