Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2407
2. Registrant Information.
Registrant Reference Number: 2009Jul APSS 90061341
Registrant Name (Full Legal Name no abbreviations): Monsanto
Address: 800 North 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-09
5. Location of incident.
Country: UNITED STATES
Prov / State: WISCONSIN
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. 71995-33
Product Name: Roundup Weed and Grass Killer Ready-To-Use Plus
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
- Guarantee/concentration 2 %
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 III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
Shih Tzu
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Head bobbing
- Symptom - Lethargy
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Exposure Information: Unknown amount dermally. Reason for exposure was accidental and was considered not applicable.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Additional details about this alleged exposure have not been provided to Monsanto Company. No additional information is expected.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
APSS Case 90061341. This substance was considered to have not related likelihood of causing the clinical situation.