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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-6837

2. Registrant Information.

Registrant Reference Number: 5638270

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.

06-JUL-16

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

07-JUN-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. 21936      PMRA Submission No.       EPA Registration No.

Product Name: WILSON ANTOUT ANT KILLER DUST (1)

  • Active Ingredient(s)
    • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

unknown

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

Mix

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

36

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

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Retching
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy
  • Respiratory System
    • Symptom - Difficulty Breathing

12. How long did the symptoms last?

Unknown / Inconnu

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

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

The owner applied a few squirts of this product around 4pCT on Sunday and Luna was out in the area about 10 mins later. The owner did not see Luna ingest the product, but it is possible she licked the plants or maybe just inhaled the product. The owner does not know the name of the plants, but does not think they were concerning. Luna has had access to that area ever since. Around 7pCT on Sunday Luna started dry heaving, but no vomiting. Around 7pCT Monday Luna started vomiting and would dry hack/seem distressed. Luna has been sort of subdue since Monday too. About 30 mins ago Luna got up and appeared to be having difficulty breathing. Luna is breathing normally now. The owner mentioned Luna and there other dogs have done this in the past, but this was the first time they noticed after the exposure to this product. Luna has an appetite and is using the bathroom normally. The owner doubts his other pets were exposed to the Wilson's product and they seem fine. The owner was advised that unless the product was squirted into Luna's face (which the owner confirmed it was not) we would not expect serious respiratory signs. If Luna inhaled some off the ground it might have caused some sneezing right away and if ingested maybe some nausea and vomiting. Our concern is something else is going on. This could be something like kennel cough, canine influenza, or possibly problems with larynx or trachea. Recommend to have Luna evaluated at eDV


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.