Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2544

2. Registrant Information.

Registrant Reference Number: 100034130

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: HAWAII

6. Date incident was first observed.

21-MAR-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. 524-370

Product Name: Roundup Concentrate Brush Killer

  • Active Ingredient(s)
    • GLYPHOSATE
      • Guarantee/concentration 18 %

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

Female

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

Unknown

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

  • Respiratory System
    • Symptom - Dyspnea
  • General
    • Symptom - Death

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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

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

Agent Exposure Roundup Concentrate Brush Killer (not specific agent id) Unknown exposure occurred on Unknown Time (unknown ). Exposure involved unknown amount by unknown route. The exposure was accidental, and occurred at animal owner yard. [Note : The owner sprayed the product this afternoon. The dog had access to the sprayed area prior (by (name) on Mar 21, 2010 at 11:06 PM)] Because the amount was unknown consistent, the patient was considered to be at medium risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. Potential Causes Roundup Concentrate Brush Killer Because the time course was poorly 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. Nerium oleander 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 : Owner called back on follow up line. Owner took the dog to clinic, passed away. Owner stated the DVM did not suspected toxicity, more likely due to old age. No necropsy. (by (name) on Mar 24, 2010 at 11:06 PM)]


To be determined by Registrant

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

Death

19. Provide supplemental information here