Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4144

2. Registrant Information.

Registrant Reference Number: 5948312

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.

02-JUL-18

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

14-JUN-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. 21936      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant 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 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

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

24

lbs

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Respiratory System
  • Symptom - Laboured breathing

• Eye
  • Symptom - Conjunctivitis

• Ear
  • Symptom - Ear irritation
  • Specify - inflammation

• Respiratory System
  • Symptom - Irritated nose
  • Specify - inflammation

• Gastrointestinal System
  • Symptom - Irritated throat
  • Specify - red throat

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

Owner applied the dust 5 days ago and x walked right through it, licked it and inhaled some of it. Shortly after the owner gave him pepto bismal because he started to have a hard time breathing. After the pepto wasnt working the owner took him into the DVM where they were thinking it was kennel cough but upon examination they ruled it out. The pet has a red throat, labored breathing, his ears and nose are inflamed. He was sent home with antibiotics, the owner also mentioned that he was not interested in eating the first couple of days afterwards but he is not eating a little more. (by LD on Jun 14, 2018 at 02:37 PM)] Because the amount was somewhat consistent, the patient was considered to be at low risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. Animal owner was advised product is mostly diatomaceous earth. IF really agitated to put a cloud into air, and then the airborne particles inhaled, could see signs of respiratory tract irritation, might lead to granulomatous reaction in lungs .Given the timeline, this does not seem likely.

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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.