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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-4411
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-14953503
Registrant Name (Full Legal Name no abbreviations): Monsanto
Address: 800 North Lindbergh Blvd
City: Saint Louis
Prov / State: Missouri
Country: USA
Postal Code: 63167
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
11-MAY-075. Location of incident.
Country: UNITED STATES
Prov / State: OREGON
6. Date incident was first observed.
Unknown
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. PMRA Submission No. EPA Registration No.
Product Name: Turf Builder Liquid Fertilizer with Plus 2 Weed Control 25-1-2
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- Guarantee/concentration 2.29 %
- MECOPROP (PRESENT AS AMINE SALTS)
- Guarantee/concentration 1.15 %
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Unknown
9. Application Rate.
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).
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
- Unknown
- Symptom - Other
- Specify - Severe Reaction
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Unknown
8. How did exposure occur? (Select all that apply)
Contact with treated area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
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.)
Son has a Tethered Cord.... was put on new medication yesterday.... had a life threatening reaction to the medication (she is sure) / could it have been the product?
To be determined by Registrant
14. Severity classification.
Major
