Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2541
2. Registrant Information.
Registrant Reference Number: 100026542
Registrant Name (Full Legal Name no abbreviations): Monsanto Canada Inc.
Address: 180 Kent Street, Suite 810
City: Ottawa
Prov / State: ON
Country: Canada
Postal Code: K1P 0B6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
12-APR-10
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
24-FEB-10
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. 524-529
Product Name: Roundup Pro Concentrate
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
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).
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
American Pit Bull Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.42
7. Weight (provide a range if necessary )
33
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
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.
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 Unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Was in good health previously. Normal environment: indoors mostly. Potential Cause Roundup Pro Concentrate (EPA 524-529) Because the time course was unknown consistent, the amount was unknown consistent, and the findings were poorly consistent, this substance was considered to have low likelihood of causing the clinical situation. [Note : Risk of GI upset and oral ulceration. Death without premonitory signs would not be expected. (by (name) on Mar 05, 2010 at 11:41 AM)] [Note : The caller wants to rule-out a possible exposure to the agent. His boss's dog died 9 days ago and there were no symptoms. He wanted to know if this agent would kill the dog. The body was cremated and no necropsy was done prior to the cremation. (by (name) on Mar 05, 2010 at 10:35 AM)] [Note : Per Dr.(name) exposures to the agent can cause GI signs but not life-threatening ones. (by (name) on Mar 05, 2010 at 09:11 AM)]
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here