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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3760

2. Registrant Information.

Registrant Reference Number: 100087686

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.

13-AUG-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

Unknown

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. 71995-33

Product Name: Roundup Weed and Grass Killer Ready To Use Plus

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
      • Guarantee/concentration 2 %

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).

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 )

Unknown

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

  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Gastrointestinal perforation

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

Signalment Age unknown male weighing unknown amount. Was in good health previously. Patient Note [Note : No known exposure to the product. (by BR on Jul 07, 2010 at 02:19 PM)] [Note : Caller stated in the phone concersation that she did not want to do an "autopsy". (by BR on Jul 07, 2010 at 02:19 PM)] The reason for the request was uncataloged agent info. This was regarding patient UNK and agent Roundup Weed and Grass Killer Ready To Use Plus. The question: Can Roundup cause death in dogs? I informed the owner that generally a mild GI upset is possible from ingesting a recently sprayed area. Once the product is dry, no significant problems are expected. The owner then stated that there was no known exposure, but that she just wanted to make sure that she did not cause any poisoning to her animal. She stated that she did not want an "autopsy" done. She also stated that on a walk, that weekend, the dog ingested a chicken/bird bone and that it may have caused the perforation in the dog's intestines. The dog died from a perforation in the GI tract. The owner and her husband have used Roundup in the past and she just wanted to rule it out. I offered to transfer her to a DVM, and she did not want to continue the call.


To be determined by Registrant

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

Death

19. Provide supplemental information here