Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-5828

2. Registrant Information.

Registrant Reference Number: 5972461

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.

11-SEP-18

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

17-AUG-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. 26193      PMRA Submission No.       EPA Registration No.

Product Name: Wilson One Shot Spiderban

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

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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. - In Home / Rés. - à l'int. maison

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: Male

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

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)

Contact with treated area

Amount of time between application and contact 3

Week(s) / Semaine(s)

What was the activity? occupying space

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.

Respiratory

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

S: Caller states the basement of the place he was living in was sprayed with Wilson One Shot Spiderban Spider Killer (Aerosol) almost 3 weeks ago. He was living there for 10 days, and by the 5th day the smell of the product was causing him dizziness and headaches. He saw his PCP, who advised him to minimize exposure. When he moved out his sxs resolved. He wants to know if there will be any long term effects. TOE: 15 days ago up to 5 days ago Med Hx: GH, no medications, NKA O: Dizziness, headache A: Chronic, adult, inhalation exposure to Wilson One Shot Spiderban Spider Killer (Aerosol), SXS R: Minimize exposure. Clean area with soap and water. Ventilate with fresh air and fans. If sxs reoccur and persist, seek medical attention. Call with questions or 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.