Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-6809

2. Registrant Information.

Registrant Reference Number: 5592817

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-MAY-16

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

04-MAR-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)

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PMRA Registration No. 21936      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant 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).

Product applied in basement around a pile of wood. Owner started bringing up the wood from the basement

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

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

11

lbs

8. Route(s) of exposure

Oral

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Respiratory System
  • Symptom - Sneezing

• Gastrointestinal System
  • Symptom - Anorexia

• Eye
  • Symptom - Conjunctivitis

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

Unknown/Inconnu

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

Product was applied in basement around a pile of wood. Owner started bringing up the wood from the basement around 2/1. Owner states there was residue from the ant dust that fell on the floor. She suspects that the cat would have walked through it and possibly licked his paws. 10 days ago the cat became lethargic and started sneezing. 2 days ago cat stopped eating. Owner took the cat to the RDVM yesterday; green ocular discharge was noted at the vet clinic in addition to an enlarged liver. DVM started the cat on antibiotics and took chest films. Radiographs are clear per owner, but then she stated that the bronchi are inflamed. The owner was advised if a small amount had been ingested, very low risk for gi upset. If a good amount had been inhaled, could see moderate to marked changes in lungs, with inflammation. AT this time, it does not sound like the product is related, but we would like to speak with the RDVM and obtain additional information. Have DVM call back to discuss the case.

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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.