Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6329

2. Registrant Information.

Registrant Reference Number: 5487263

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.

23-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. 9802      PMRA Submission No.       EPA Registration No.

Product Name: Wilson 50 Mlathion Liquid Insecticide Miticide

• Active Ingredient(s)
  • MALATHION

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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.

Other

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Diarrhea

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)

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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 TC caller stated her mother used the product last week and the weekend twice. Outside spraying her garden for about 15minutes. She did not have a mask on during use. She did remove her clothing and took a bath after each use. The patient hasHTN taking medication daily for it. Confirm she did not ingest the product.O, Symptoms c o,nauseacan smell a burning odordiarrheaA, Acute Adult inhalation exposure to Wilson 50% Malathion Liquid Insecticide MiticideI spoke with daughter of person affected, She sprayed it on her roses a couple times last week for the bugs.She came into the how after spraying. She then changed her clothes and took a bath.Patient lives with her husband the husband doesn t smell anything in the home. Patient came right over to her mother s home when she said it smelled like something was burning Caller could not smell anything unusual either.Their house is 2 years old.HEALTH HX, GH, allergy, seasonal, meds, antihypertensive tevalosartan potassium ,on it for 10 years, O No lacrimation.No rhinorrhea.The smell is making her nauseated (started last Thursday and Friday)..No vomiting.No sweating.A, Per MSDS,Malathion 50%Petroleum Distillates 4050%Acute possible inhalation or dermal exposure to organophosphate in an adult. Symptomatic.R, Reviewed SLUDGE syndrome.I do not believe Patients signs sx are related to the malathion. Consider other etiology.She has a follow up appointment with her physician in a few days (but can go to ER if they are concerned).Call as needed. CC

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.