Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2823

2. Registrant Information.

Registrant Reference Number: 5707089

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-NOV-16

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

31-OCT-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. 28353      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat And Mouse Killer Pellets Place Pac

• Active Ingredient(s)
  • DIFETHIALONE

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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

unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Diarrhea

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 has these two types of baits placed out around his house and he believes it was possible that the dog got ahold of some of it. The owner explained that there was no possible way that the dog got ahold of the Wilson Predator blocks because they are nailed to the ground in the basement and the dogs do not go in the basement. The only one that is possible is the the Wilson Predator bait pellet packs. The owner has seen no evidence of an exposure to this, but he believes that if some rat or mouse pulled out the pack then possibly the dog could get to it. The owner also thinks it's possible that the dog could have eaten a dead rat that could have died from this product, but the owner has seen no evidence of ingestion of a dead rat. The dog has been lethargic and has had dark loose stool for the past 3 days. The caller was advised to take the dog to clinic and have them run a PT, PTT test to check the clotting ability of the blood, and to see if there is any indication of the bait in the blood. Provided the case and call back number to have the vet call us directly for a treatment plan. Outcome unknown

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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.