Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-6807

2. Registrant Information.

Registrant Reference Number: 5585880

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-16

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

17-FEB-16

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: Wilson Wilsarin Rat And Mouse Killer Pellets

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

---

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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Rough Collie

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

20

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

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?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

Puppy may have ingested a mouthful of bait. He was taken to clinic and vomited in the car on the way there. Hay in vomitus. No bait seen. Because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. Risk is for GI upset, impaction and GI FB. Vet confirmed that pet vomit did contain green color but also what may be hay. He was at the barn today so he may have also eaten horse manure. Recommended bulking diet. Monitor for signs of GI FB. Call back with questions

---

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. 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.