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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-2082

2. Registrant Information.

Registrant Reference Number: 5524983

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.

05-NOV-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

07-OCT-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. 30535      PMRA Submission No.       EPA Registration No.

Product Name: Wilsarin Rat and Mouse Killer

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

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).

in trailer

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

  • Cardiovascular System
    • Symptom - Chest pain
  • Respiratory System
    • Symptom - Shortness of breath
  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • Cardiovascular System
    • Symptom - Other
    • Specify - feels like she's having a "heart attack".

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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

Amount of time between application and contact 2

Week(s) / Semaine(s)

What was the activity? re-entering trailer

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 states that they placed at and Mouse Killer in trailer underbed x 1 to 2 weeks ago.Product: Wilsarin by Wilson, Rat and Mouse Killer,pink crystals put 3 to 4 bags of the product around.Callers concerned on the box it says to not inhale it.Denies actual mice in the trailer.Both caller and sister have symptoms O:caller not feeling well today,feels like she's having a "heart attack".sob,dizzy Sister is achey and has cough A: chronic adult inhalation of Wilsarin by Wilson Rat and Mouse Killer crystals, symptomatic R: hang up and call 911 seek care Should remove the product, call 911, and don't go back in home until know it is safe call back as needed pc will follow. Unable to follow as follow up calls did not connect, outcome unknown.

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. Also product is composed from corn cellulose, one would not expect chest pain type symptoms from corn.

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

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Coughing
  • Nervous and Muscular Systems
    • Symptom - Aching

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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

Amount of time between application and contact 2

Week(s) / Semaine(s)

What was the activity? re-entering the trailer

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 states that they placed at and Mouse Killer in trailer underbed x 1 to 2weeks ago.Product: Wilsarin by Wilson, Rat and Mouse Killer,pink crystals put 3 to 4 bags of the product around.Callers concerned on the box it says to not inhale it.Denies actual mice in the trailer.Both caller and sister have symptoms O:caller not feeling well today,feels like she's having a "heart attack".sob,dizzy Sister is achey and has cough A: chronic adult inhalation of Wilsarin by Wilson Rat and Mouse Killer crystals, symptomatic R: hang up and call 911 seek care Should remove the product, call 911, and don't go back in home until know it is safe call back as needed pc will follow. Unable to follow as follow up calls did not connect, outcome unknown.

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. Also product is composed from corn cellulose, one would not expect chest pain type symptoms from corn.