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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4902
2. Registrant Information.
Registrant Reference Number: 100103868
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.
15-SEP-105. Location of incident.
Country: UNITED STATES
Prov / State: ILLINOIS
6. Date incident was first observed.
02-AUG-10Product 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. 71995-29
Product Name: Roundup Weed and Grass Killer Concentrate Plus
- Active Ingredient(s)
- DIQUAT, PRESENT AS DIBROMIDE
- Guarantee/concentration .73 %
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
- Guarantee/concentration 18 %
- DIQUAT, PRESENT AS DIBROMIDE
7. b) Type of formulation.
Other (specify)
ConcentrateApplication 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
Cat / Chat
3. Breed
Shorthair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Respiratory System
- Symptom - Epistaxis
- General
- Symptom - Lethargy
- Gastrointestinal System
- Symptom - Anorexia
- Respiratory System
- Symptom - Abnormal lung sounds
- Specify - Moist Lung Sounds
- 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?
No
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 10.0 yr neutered male weighing 12.0 lb. Was in good health previously. Normal environment: indoors mostly. Patient Note [Note : Owner noted that the cat has fluid in the lungs 2 months ago and again now. (by DM on Aug 09, 2010 at 11:43 AM)] Agent Exposure Roundup Weed and Grass Killer Concentrate Plus (possible agent id) Possible exposure occurred on Aug 02, 2010 at 11:35 AM CDT (no expo ). Exposure involved unknown amount orally. The exposure was accidental, and occurred at animal owner yard. [Note : Cat was outside Wednesday night and may have ingested some grass with the product. Family was unable to find until Friday morning. (by AF on Aug 09, 2010 at 11:23 AM; amended by DM on Aug 09, 2010 at 11:43 AM)] 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. [Note : Risk of GI upset: mild vomiting and hypersalivation. These signs are not consistent. (by DM on Aug 09, 2010 at 11:43 AM)]
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
