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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-6866

2. Registrant Information.

Registrant Reference Number: 5650750

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.

11-AUG-16

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

04-JUL-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. 9802      PMRA Submission No.       EPA Registration No.

Product Name: Wilson 50% Malathion

  • Active Ingredient(s)
    • MALATHION

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. - Out Home / Rés - à l'ext.maison

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

applied with a sprayer

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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Vomiting
    • Symptom - Stomach pain
  • Respiratory System
    • Symptom - Shortness of breath
  • General
    • Symptom - Sweating
  • Gastrointestinal System
    • Symptom - Stomach pain
  • Renal System
    • Symptom - Kidney pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

Application

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.

Skin

Oral

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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 stated that he was using a sprayer to put the product on to some ants . It was diluted with water at the time , it was windy and blew back on him. Caller was not wearing a mask and at the time a short sleeve shirt. The product had got on his skin and he inhaled it. gh and nka O: he has been in to the ER x 4 and they do not know what is wrong TOE was Thursday afternoon sxs started the next day on Friday he had vomiting, diarrhea and sweating on Friday but that has resolved. He also has pain around his stomach and kidneys that is not improving he was also short of breath on Friday but that has improved. A: acute adult inhalation and dermal exposure symptomatic R: recommend to wash off with soap and water in shower x 3 and disregard any leather that was worn at the time of exposure recommend to go back to ER and have MD CB to speak with tox about his sxs . 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.