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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0620

2. Registrant Information.

Registrant Reference Number: 90089352

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.

Domestic Animal

4. Date registrant was first informed of the incident.

22-JAN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

06-AUG-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. 71995-29

Product Name: Roundup Weed and Grass Killer Concentrate Plus

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS MONO-AMMONIUM SALT OR DIAMMONIUM SALT)
      • Guarantee/concentration 18 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 71995-29

Product Name:

  • Active Ingredient(s)
    • DIQUAT
      • Guarantee/concentration .73 %

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).

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

unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

30

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

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Drooling
  • General
    • Symptom - Death

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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

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

Roundup Weed and Grass Killer Concentrate Plus (observed agent id) Possible exposure occurred on Aug 02, 2009 at 12:00 PM CDT (not specific ). Exposure involved 0.0 Not App (not specific) orally. The exposure was accidental, and occurred at animal owner yard. The agent was obtained from Other Retailer. The lot number was DNA. The expiration date was null. [Note : Owner used the diluted product 1 week ago. Owner thinks the product was dry before the dog had access. Starting 2 days ago, the dog began to vomit, have diarrhea, is lethargic and drooling excessively. Owner has been forcing food and water down the dog, but the dog is unable to hold anything down. (by (name) on Aug 08, 2009 at 12:26 PM)] Because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. [Note : At most would expect mild self-limiting GI upset. Signs consistent with more severe gastrointestinal disease (viral, bacterial, etc.). (by (name) on Aug 12, 2009 at 12:20 PM)]


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

Because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. [Note : At most would expect mild self-limiting GI upset. Signs consistent with more severe gastrointestinal disease (viral, bacterial, etc.). (by SG on Aug 12, 2009 at 12:20 PM)]