Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5976

2. Registrant Information.

Registrant Reference Number: 5407059

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.

03-MAR-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

02-FEB-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)

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PMRA Registration No. 29166      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Homecare Mouse And Rat Killer Pellet

• Active Ingredient(s)
  • CELLULOSE (FROM POWDERED CORN COBS)

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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

Cat / Chat

3. Breed

Domestic ShortHair

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2.5

7. Weight (provide a range if necessary )

14.1

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Bloody vomit
  • Symptom - Anorexia

• General
  • Symptom - Dehydration

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?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

specify unknown

17. Provide any additional details about the incident

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

Owner has 10 cats. About 1 week ago 5 of the cats started vomiting kibble. About 3 days ago they started to vomit blood. Porkchop was the only cat brought into the clinic today around 1345CST. No treatments performed. Owner does not know if the cats were exposed to this product or not. This is the only thing the owner can think of that they could have been exposed to. The owner was advised that would expect at most mild GI upset may be seen. Spoke to DVM, 5 cats started to get sick a week ago. The cats are not eating, not drinking, not using the littlerbox. Normal temp, dk stool. Mildly pale mm. Discussed that the product would not be expected to cause these signs especially for a prolonged period of time. Discussed caustic cleaning agents but the owner does not keep a lot of chemicals in the home. No known dropped pills. Discussed lab work on the cat that is there now.

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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

Unable to provide any other information on the 4 other cats as the owner only brought one in for medical attention. No other mention of other case throughout the case.