Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-6816
2. Registrant Information.
Registrant Reference Number: 5606128
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.
16-MAY-16
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
02-APR-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. 27017
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Ant raps
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
border Collie
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
.75
7. Weight (provide a range if necessary )
60
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Anorexia
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Was medical treatment provided? Provide details in question 17.
No
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
Caller states that her dog ingested this product yesterday and had symptoms of diarrhea and anorexia. Caller states that the dog is better today. TOE 1 day ago. R: Wash muzzle/paws. Have fresh water available. Watch for any changes in bowel/eating habits. If sx persist, consult veterinarian
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.