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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0623

2. Registrant Information.

Registrant Reference Number: 90097124

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.


5. Location of incident.


Prov / State: TEXAS

6. Date incident was first observed.


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.


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

Product Name: Roundup Weed and Grass Killer Concentrate Plus

  • Active Ingredient(s)
    • DIQUAT
      • Guarantee/concentration .73 %
      • Guarantee/concentration 18 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'

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?


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Vomiting
  • Skin
    • Symptom - Pale mucous membrane colour
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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 (suspected agent id) Suspected exposure occurred on Aug 26, 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 home. The agent was obtained from Other Retailer. The lot number was 109098-f115. The expiration date was null. [Note : The owner suspects that the dog was exposed to the agent on 08/26/09. She vomited several times and yesterday 08/27/09 the dog passed away. She wants to know if this is related to the exposure. Molly was buried yesterday. (by (name) on Aug 28, 2009 at 10:59 AM)] Because the amount was unknown consistent, the patient was considered to be at low risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. [Note : Exposure to this product is expected to cause mild, self limiting GI signs. (by (name) on Sep 07, 2009 at 09:24 AM)]

To be determined by Registrant

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


19. Provide supplemental information here

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