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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3135

2. Registrant Information.

Registrant Reference Number: 2010-21

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA


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. 27946      PMRA Submission No.       EPA Registration No.

Product Name: Renegade HC

  • Active Ingredient(s)

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: Other / Autre

Préciser le type: large junk yard

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

He said the Renegade HC is in a 5L container and he mixes ¿ a Campbells soup can to 2 gallons of water. (He has a 5 gallon container to do the mixing.)

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.



11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

(name) said his employer has him apply Renegade HC for 5-8 hours at a time (and was told you can wash your hands in it/drink it and it¿s completely safe). He¿s been spraying a large junk yard to kill all the weeds. He¿s been doing this for 5 days. He does not wear a mask or gloves (sometimes coveralls and rubber boots, but if it¿s too hot, then just shorts). If windy, he does get spray back in his face/eyes. He feels really ill after applying and it usually goes away after a day or so. (Feels very nauseated but does not vomit). He said the Renegade HC is in a 5L container and he mixes ¿ a Campbells soup can to 2 gallons of water. (He has a 5 gallon container to do the mixing.) He thought there was mention of not entering the area for 7-14 days after applying on the label.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.