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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-5825

2. Registrant Information.

Registrant Reference Number: 5969553

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. 28353      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Rat & Mouse Killer Pellets

  • 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: Res. - Out Home / Rés - à l'

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?


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

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Headache
  • Respiratory System
    • Symptom - Difficulty Breathing

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)

Contact with treated area

What was the activity? entering the shed where bait was placed

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.

<=30 min / <=30 min

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.)

08/09/18 19:46 Caller states that he was in the shed where the product was. He states that product looked like it had been eaten. He states that he may have inhaled the dust. TOE: few minutes ago Gh No Med Allergies: pollen, peanut O: a little chest tightness. slight headache. A: Acute adult inhalation exposure to Wilson Predator Rat Mouse Killer Pellets Place Packs: SX R: Ventilate indoor areas. Get plenty of fresh air If symptoms persist, inhale steam from shower. Keep hydrated If difficulty breathing, persistent cough, or prolonged symptoms occur, seek medical attention PC advised caller that he can take an OTC mediation that he would normally take for a headache. PC will cb in 1 hour for follow up. 08/09/18 20:54 b to (name) to see how he is doing after his exposure. Caller states that his chest still hurts. He states that he did the steam. Caller also states that his chest hurts when he stand up and walks around, when sitting it doesn't hurt that much. O: chest hurts headache better. A: Acute adult inhalation exposure to Wilson Predator Rat Mouse Killer Pellets Place Packs: SX R: PC advised caller to seek medical attention due to sxs. PC will cb tomorrow for follow up. 08/10/18 09:36 CB performed to number provided. Caller states he did not go to a physician. He repeated steam inhalation and states his SX resolved on their own. O: ASX A: Acute adult inhalation Wilson Predator Rat Mouse Killer Pellets Place Packs ASX R: Call back with questions/concerns.

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.