Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-2682
2. Registrant Information.
Registrant Reference Number: 2008Jun APSS 80065535
Registrant Name (Full Legal Name no abbreviations): Monsanto
Address: 800 N. Lindbergh Blvd.
City: Saint Louis
Prov / State: Missouri
Country: United States of America
Postal Code: 63167
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
14-JUL-08
5. Location of incident.
Country: UNITED STATES
Prov / State: OHIO
6. Date incident was first observed.
12-JUN-08
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. 524-308
Product Name: Roundup Herbicide
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
- Guarantee/concentration 41 %
7. b) Type of formulation.
Liquid
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).
Owner's neighbor sprayed his yard and the area adjacent to the owner's fence with Roundup possibly on June 10, 2008.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
Pomeranian
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.79
7. Weight (provide a range if necessary )
5
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog began to vomit on June 15, 2008. On June 16, 2008, dog would not eat or drink. Owner gave pedialyte with an eye dropper but dog continued to vomit. Owner found dog dead on June 17, 2008.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
APSS Case ID: 80065535. Because the time course was unknown consistent, the amount was unknown consistent, and the findings were poorly consistent, this substance was considered to have not related likelihood of causing the clinical situation.
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
Boxer
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.58
7. Weight (provide a range if necessary )
40
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owners found dog dead on June 12, 2008, around 6pm. Dog was outdoors all day from June 10-12, 2008.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
APSS Case ID: 80065535. Because the time course was unknown consistent, the amount was unknown consistent, and the findings were poorly consistent, this substance was considered to have not related likelihood of causing the clinical situation.