Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6091

2. Registrant Information.

Registrant Reference Number: 5490782

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.

07-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-JUL-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. 28793      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Ant Out Ant Bait

• Active Ingredient(s)
  • BORAX

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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 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Lesion
  • Specify - Laceration

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

Unknown

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.

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

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.)

S: When caller opened the product container, she cut her thumb. TOE: 15 mins ago. She has washed and bandaged her finger.Caller wished to be transferred to CS after call was completed.High BP meds for BP Seasonal allergiesO: LacerationA: Acute adult dermal Wilson Ant Out Ant Bait SXR: Keep wound clean and dry.Monitor for signs of infection.If SX occur, consult a physician.Caller transferred to CS.CB scheduled.S: Cb from caller stating that she can' get through to CS. PC will warm transfer caller to CS VM.O:A:R:S: CB to number given, spoke with patient who stated her finger is still a little sore but she believes it is healing. Patient alsostated she is using a creme/ointment on the skin.O: Symptom c/o:laceration improvingA: Acute adult dermal exposure to:Wilson Ant Out Ant BaitR:

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.