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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5965

2. Registrant Information.

Registrant Reference Number: 5441383

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.

05-MAY-15

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

21-APR-15

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. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin, Rat and Mouse Bait Pellets

  • Active Ingredient(s)
    • BROMADIOLONE

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Black Lab

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

.25

7. Weight (provide a range if necessary )

30

lbs

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

  • Respiratory System
    • Symptom - Laboured breathing

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

TC from owner of dog he is enroute to Emergency vet office now 4 month old black lab got into wilson wilsarin rat and mouse bait pellets 60 grams packet and he ate at least 1/4-1/2 of one packet PCP unable to find the number caller pulled up in front of Vet office at end of the phone call. O: TOE was 12 hours ago dog has labored breathing and very thirsty weighs 30 lbs. A: acute animal oral exposure symptomatic per calculator for 1/4 pack or 15 grams Dog ingested .0551 mg per KG of BW Bromadiolone .005%. This amount exceeds the threshold: 10.896 g. R: recommend to take dog to Emergency Vet and have Vet CB to PC for consult with NAPCC. caller given phone # and PC # to give to Vet if no CB will cc/PD


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.