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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4905

2. Registrant Information.

Registrant Reference Number: 100110192

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.


5. Location of incident.


Prov / State: WISCONSIN

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.       PMRA Submission No.       EPA Registration No. 71995-29

Product Name: Roundup Weed and Grass Killer Concentrate Plus

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

7. b) Type of formulation.

Other (specify)


Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'

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?


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Fish / Poisson

3. Breed

Gold Fish

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


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


  • General
    • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Other / Autre

specify weeds sprayed next to a pond

17. Provide any additional details about the incident

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

Gold Fish group of 50 (Fish) Signalment 0.0 DND N/A weighing 0.0 DND. Agent Exposure Roundup Weed and Grass Killer Concentrate Plus (observed agent id) Unknown exposure occurred on Aug 18, 2010 at 12:00 PM CDT¿1 day (not specific ). Exposure involved 0.0 Not App (not specific) by unknown route. [Note : Owner is going through a divorce, he is not currently living at the residence where the fish reside. Owner's suspects his wife sprayed the weeds with roundup next to the pond on Tuesday or Wednesday. Owner said the fish began to die around Friday or Saturday. There are over 100 fish in the pond. They are still slowly dying. Owner wants to know if this is the cause of death. (by AA on Aug 22, 2010 at 04:53 PM)] Because the amount was unknown consistent, the patient was considered to be at unknown risk of developing clinical signs. If signs develop, there is unknown risk that those signs will be life-threatening. [Note : There is no way to tell if the Roundup is in the water at this point; there are multiple causes for acute fish kill in a pond environment. A veteriarian should be consulted regarding assisting this case. (by MK on Aug 24, 2010 at 03:44 PM)] Clinical Status Death {General Disorders} [Note : number of fish dead/dying are not described by the caller (by MK on Aug 24, 2010 at 03:44 PM)] Status: Death Potential Cause Roundup Weed and Grass Killer Concentrate Plus Because the time course was unknown consistent, the amount was unknown consistent, and the findings were unknown consistent, this substance was considered to have unknown likelihood of causing the clinical situation. Koi group of 50 (Fish) Signalment 0.0 DND N/A weighing 0.0 DND. Outcome Unknown

To be determined by Registrant

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


19. Provide supplemental information here