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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0917

2. Registrant Information.

Registrant Reference Number: 100166050

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.

07-JAN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

23-DEC-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. Unknown

Product Name: Round Up

  • Active Ingredient(s)
    • GLYPHOSATE
      • Unknown

7. b) Type of formulation.

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

Golden Retreiver

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.33

7. Weight (provide a range if necessary )

27

lbs

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

  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Death
  • Respiratory System
    • Symptom - Other
    • Specify - bleeding in lungs
  • Gastrointestinal System
    • Symptom - Other
    • Specify - bleeding in intestines

12. How long did the symptoms last?

Persisted until death

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

Yes

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

Golden Retriever named Joseph (Canine Domestic) Signalment 4.0 mo immature male weighing 27.0 lb. Was in excellent health previously. Normal environment: indoors mostly. Clinical Status Vomiting {Digestive} Begin: Dec 23, 2010 at 06:00 PM CST¿4 hr Status: Moderate Death {General Disorders} Permanent: Dec 24, 2010 at 05:00 AM CST Status: Death Potential Causes Roundup Weed and Grass Killer 1 Ready To Use Because the time course was unknown consistent, the amount was unknown consistent, and the findings were not consistent, this substance was considered to have not related likelihood of causing the clinical situation. Anticoagulant Rodenticide (Unknown) Because the time course was unknown consistent, the amount was unknown consistent, and the findings were generally consistent, this substance was considered to have medium likelihood of causing the clinical situation. Patient Care Unplanned Care Take Animal to Veterinarian Details: Performed Dec 23, 2010 10:00 AM Fluid Therapy Details: Performed Dec 23, 2010 10:00 AM Blood Transfusion Details: Performed Dec 23, 2010 10:00 AM Necropsy Details: Performed Dec 23, 2010 10:00 AM [Note : Blood in the lungs, intestines, etc. (by KS on Dec 27, 2010 at 03:40 PM)] Vitamin K1 - Dog Details:According to owner did not help Performed Dec 23, 2010 10:00 AM Potassium - Dog Details:Fluid additive Performed Dec 23, 2010 10:00 AM Parvovirus Test Details:Negative Performed Dec 23, 2010 10:00 AM Outcome Died , EPA max illness designation: D-A List of Contacts Dec 27, 2010 at 03:32 PM CST (veterinarian) interacted with (owner) for reason: obtain help. [Note : Caller thinks (name) was poisoned. On 12/23, Joseph started vomiting. He went to the vet and died on 12/24/2010. Caller says the autopsy reports bleeding in the lungs. Caller wants to know if Roundup could cause this. (by KS on Dec 27, 2010 at 03:58 PM)] [Note : Discussed case with owner. Round Up is used around the apartment complex, owner is concerned that dog had some sort of exposure. Advised Round Up would not cause this, anticoagulant rodenticide should be considered, but VK1 and blood transfusion should have been effective treatment. (by KS on Dec 27, 2010 at 03:40 PM)]


To be determined by Registrant

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

Death

19. Provide supplemental information here