Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4102

2. Registrant Information.

Registrant Reference Number: 5914646

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.

19-APR-18

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

11-MAR-18

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. 26679      PMRA Submission No.       EPA Registration No.

Product Name: HomeCare Bed Bug & Crawling Insect 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. - 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).

they put it in the seam on the couch .

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

unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Vomiting

• Respiratory System
  • Symptom - Respiratory distress

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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

3/11/2018 00:25 S: TC from owner of cat green earth home care bedbug and crawling insect bug PCP 26679. They put it in the seam on the couch and she may have walked on it or sniffed at it. Caller would not say when product was placed in couch no witnessed exposure. O: she has been lethargic for few days tonight she is vomiting and having difficulty breathing A: unknown animal possible inhalation or dermal exposure symptomatic R: relayed would not expect these sxs with this type of exposure recommend to take cat to Vet asap given case # to reference if no CB will cc/PD 3/11/2018 01:28 S: Call from animal DVM Reviewed PC recommendations Per DVM the cat has been sick for a week, she does not think symptoms are related to this exposure.

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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.