Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4104

2. Registrant Information.

Registrant Reference Number: 5921243

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.

01-MAY-18

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

01-APR-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: 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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

• Respiratory System
  • Symptom - Nose bleed

• Gastrointestinal System
  • Symptom - Mouth Irritation

• Eye
  • Symptom - Pain
  • Symptom - Irritated eye

• General
  • Symptom - Other
  • Specify - sores in mouth, nose and ears

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.

Oral

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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 used some HomeCare Bed Bug Crawling Insect Killer Dust and got some of the product on her hands. She is concerned that she may have put her hands in her mouth after using product and ingested some of product. Caller states that she has been experiencing a bloody nose and sores ("pustules") in her mouth, nose, and ears that come and go. She states that she frequently rubs her eyes and is experiencing ocular irritation. She was seen and treated at an ED and she has an appointment to see her PCP this week. Caller also states that she gets a rash when using certain facial products. Went over MSDS with caller. TOE: 5 days ago Diabetes, fibromyelgia, bladder infection, gallbladder stones, T6 antibiotics Allergy to penicillin and aspirin O: bloody nose sores in mouth, nose, ears ocular irritation rash A: Acute, adult, ingestion/ocular, exposure to HomeCare Bed Bug Crawling Insect Killer Dust, SX R: Recommended seeking medical attention for symptoms that are likely not related to product. Instructed caller to discontinue use of product, but she states that she cannot afford to get bed bugs and may continue to use product. Informed caller that she should wash any affected areas with soap and water and to discontinue use of ANY product that may be resulting in symptoms. Caller will consult with her physician for treatment of these symptoms. Gave caller case/phone number for any further questions/concerns.

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.