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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3761

2. Registrant Information.

Registrant Reference Number: 100088699

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: MISSISSIPPI

6. Date incident was first observed.

07-JUL-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. 71995-17

Product Name: Roundup Concentrate Weed And Grass Killer 1

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
      • Guarantee/concentration 18 %

7. b) Type of formulation.

Other (specify)

Concentrate

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

Rat Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • General
    • Symptom - Lethargy
  • Gastrointestinal System
    • Symptom - Rectal hemorrhage
  • 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

Signalment 6.0 yr neutered female weighing 10.0 lb. Normal environment: indoors mostly. Patient Note [Note : Dog was attacked by another dog about a month ago. Dog has made a full recovery. (by JS on Jul 09, 2010 at 01:09 PM)] Agent Exposure Roundup Concentrate Weed And Grass Killer 1 (suspected agent id) Possible exposure occurred on Jul 07, 2010 at 01:19 PM CDT¿1 day (suspected ). Exposure involved unknown amount orally. The exposure was accidental, and occurred at animal owner yard. [Note : Product was mixed and used 2-3 days ago. Dog had access to area where product was sprayed. (by JS on Jul 09, 2010 at 01:09 PM)] 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. Potential Cause Roundup Concentrate Weed And Grass Killer 1 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. Jul 09, 2010 at 01:09 PM CDT (name)(assistant) interacted with Ms. (name) (extended family) for reason: obtain help. [Note : Spoke with owner. Dog may have been exposed to a Roundup product over the last several days, however this is not certain. Last night, dog began bleeding from her rectum, and dog has been very lethargic today. Roundup product not certain or available right now. Per Dr. (name) Rectal bleeding is not a sign we would expect from this product at all. We would mainly see GI upset, vomiting, possibly diarrhea. Even if the dog ate the concentrated product, we would not see rectal bleeding. Dog should go into a vet for further evaluation. (by JS on Jul 09, 2010 at 01:24 PM)] Jul 13, 2010 at 03:39 PM CDT (name) (assistant) interacted with Ms. (name) (extended family) for reason: monitor case-out. [Note : Called owner to update the case. The owner informed me that the pet died later, as I was offering my condolences to her she hung up on me. (by DG on Jul 13, 2010 at 03:49 PM)]


To be determined by Registrant

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

Death

19. Provide supplemental information here