Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6093

2. Registrant Information.

Registrant Reference Number: 5501246

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.

04-SEP-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

20-AUG-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. 26622      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Slug and Bug Killer Dust

• Active Ingredient(s)
  • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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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. - In Home / Rés. - à l'int. maison

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

Applied along door sill

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

• General
  • Symptom - Swelling

4. How long did the symptoms last?

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

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)

Contact with treated area

What was the activity? locks being change, dust adjitated

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?

>1 wk <=1 mo / > 1 sem < = 1 mois

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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 using green earth slug and bug insect killer broke out in bruises purple dots and turns red, raises to surface all over today caller has low blood pressure and has not slept for 3 days. Caller had this spread across her door because she has tons of earwigs Locksmith had to replace locks yesterday. He had the door open. She had a bamboo map. Somehow it got in her house. She did not realize that could not touch this. She phoned her doctor because she just got out of the hospital. She got out of the hospital for an over dose She has depression and anxiety. She has not been able to sleep for 3 days. She takes Effexor XR, Prozac, Clonazepam and singulair, and something for sleep. She has been breathing this stuff in for the last 4 weeks. It was put out about a month ago. First symptoms started today. It has been all over her body. It says not to touch or inhale. Every time she washes she gets worse. R: We are here 24/7. Take the product to the doctor and have him call. This product is not expect to be a big problem tox wise It is an irritant. Generally considered to be safe around pets, etc. Can be sensitive to this product. Normally would say to wash off with soap and water but if symptoms are persisting seek medical evaluation Your dermal symptoms are more than would expect and would not expect you to have all this swelling.

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.