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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2894

2. Registrant Information.

Registrant Reference Number: 2009Aug APSS 90075752

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.

13-AUG-09

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

6. Date incident was first observed.

02-JUL-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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 524-535

Product Name: QuikPro Herbicide

  • Active Ingredient(s)
    • DIQUAT
      • Guarantee/concentration 2.9 %
    • GLYPHOSATE (PRESENT AS MONO-AMMONIUM SALT OR DIAMMONIUM SALT)
      • Guarantee/concentration 73.3 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. NA

Product Name: Preemergent Herbicide (Unknown)

  • Active Ingredient(s)

7. b) Type of formulation.

Granular

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).

Product was sprayed in pet owner's yard around July 1, 2009.

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

Miniature Pinscher

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.67

7. Weight (provide a range if necessary )

8

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

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Vomiting
  • Respiratory System
    • Symptom - Wheezing
  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Death

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?

Yes

14. b) How long was the animal hospitalized?

1

Day(s) / Jour(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The owner suspects that the dog may have been exposed to the agent that he sprayed in the yard. The puppy was symptomatic 1 or 2 days later. The owner took the dog to the ER and the puppy was given IV fluid, antibiotic (amoxicillin), and an unknown pain shot. The dog was not exposed to the wet product. Dog was back home on July 5, 2009. The dog died at home. Time of death was not specific. The death was reported in conversation with pet owner and noted on July 16, 2009.


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: 90075752. Because the time course was poorly consistent, the amount was poorly consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation.