Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0521

2. Registrant Information.

Registrant Reference Number: 31739609

Registrant Name (Full Legal Name no abbreviations): Monsanto Canada Inc.

Address: 350 Albert St, Suite 315

City: Ottawa

Prov / State: ON

Country: Canada

Postal Code: K1R 1A4

3. Select the appropriate subform(s) for the incident.

Human

Packaging Failure

4. Date registrant was first informed of the incident.

25-JAN-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

29-DEC-09

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.       PMRA Submission No.       EPA Registration No. 71995-21

Product Name: Roundup Extended Control Weed and Grass Killer 1 Plus Weed Preventer

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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?

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Abnormal lung sounds

• General
  • Symptom - Taste altered
  • Specify - salty taste on lips with a burning sensation

• Respiratory System
  • Symptom - Shortness of breath
  • Symptom - Respiratory pain

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Unknown

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

Application

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

10. Route(s) of exposure.

Respiratory

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Caller states several days ago, a 2 gallon Roundup Extended Control Ready to Use, leaked from the loose cap of the bottle, in the trunk of his car. Some evaporated in the heat and corroded some metal pieces that were in the trunk. The vehicle is at the car shop now. The caller is concerned about the leakage in the trunk space and being in the car with the smell. When sleeping last night, he heard popping noises in his breath and had a salty taste on his lips with a burning sensation. (name) discussed the product toxicity. Symptoms do not correspond to the expected response to the product. Referred the caller to the company for car clean up information. Man called back in another 2 days to state that 2 nights ago he had shortness of breath and like chest pain. Last night he was fine and he is feeling better today. Symptoms do not correspond to the expected response to the product. (name) advised the symptoms are worthy of notification of being seen by MD.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Symptoms do not correspond to the expected response to the product, not likely the cause of symptoms.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Bottle-plastic / Bouteille-plastique

2. Did packaging failure occur during?

Transportation

3. Did packaging failure result in?

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Caller states several days ago, a 2 gallon Roundup Extended Control Ready to Use, leaked from the loose cap of the bottle, in the trunk of his car.

For Registrant use only

5. Provide supplemental information here.

No information provided if new unopened product or opened previously.