Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-6087
2. Registrant Information.
Registrant Reference Number: 5505499
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.
04-SEP-15
5. Location of incident.
Country: CANADA
Prov / State: Quebec
6. Date incident was first observed.
29-AUG-15
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)
PMRA Registration No. 29822 PMRA Submission No. EPA Registration No.
Product Name: Green Earth Weed and Grass Killer
- Active Ingredient(s)
- ACETIC ACID
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. – Out Home / Rés – à l’ext.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.
Other
2. Demographic information of data subject
Sex: Female
Age: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom – Vomiting
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
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 2
Day(s) / Jour(s)
What was the activity? walking around barefooted
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.
Skin
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>24 hrs <=3 days / >24 h <=3 jours
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.)
The caller applied the product to his driveway and 2 days later, his granddaughter was playing in the area barefoot. TOE: 3 days ago. Today, she has vomited twice. Wants to know if SX may be related. GH; no meds; NKA R: SX do not sound related to exposure.
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.
Source: Pesticide Product Information – Health Canada