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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4132

2. Registrant Information.

Registrant Reference Number: 5969865

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.


PMRA Registration No. 18868      PMRA Submission No.       EPA Registration No.

Product Name: CIL AMBUSH Tree and Garden Insect Killer

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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).

Has been using the product for many years! one week prior to his symptoms he stated that he had been using the product daily.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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.


  • Cardiovascular System
    • Symptom - Hypotension
  • Nervous and Muscular Systems
    • Symptom - Dizziness
  • Eye
    • Symptom - Blurred vision

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.



11. What was the length of exposure?

<=15 min / <=15 min

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.)

8/10/2018 15:40: Caller has been using this product for years and prior to one week ago he was spraying this product daily for a few days for 10 minutes at a time. He states about 1 week ago he started feeling light headed and when he took his blood pressure he noticed it was significantly lower than his normal baseline. He states he has been feeling "woozy" and has been laying down frequently these past few days. TOE: a few yearsMed hx: GH, no medications, NKA O: Hypotension, light headedness A: Chronic, adult, inhalation exposure to CIL AMBUSH Tree and Garden Insect Killer, SXS R: Attempted to transfer to CSPI. Caller disconnected during hold. Notified CSPI for CB. 8/10/2018 15:58: Called caller back. Trying to see if low BP has any association to last used product, CIL AMBUSH Tree and Garden Insect Killer on Monday, 6 days ago, and BP still too low, 84/69, then 90/63. First noticed Sunday afternoon, had trouble seeing/vision problems driving home. Appointment on the 22nd. R: Urged to follow up with primary health care provider. Since caller has used product for years without symptoms, unlikely that product use has any relation to low blood pressure. If symptoms are causing loss of balance, urged to go in to be seen by health care provider sooner than the scheduled appointment on the 22nd.

To be determined by Registrant

14. Severity classification.


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. Permethrin has been determined by research to have low to no effect on humans. Based on the callers age, one would think that it is more related to that then the product itself.