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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2718

2. Registrant Information.

Registrant Reference Number: 2011-08

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.

Human

4. Date registrant was first informed of the incident.

28-FEB-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

17-MAY-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. 27487      PMRA Submission No.       EPA Registration No.

Product Name: Roundup Weathermax with Transorb 2 Technology

  • Active Ingredient(s)
    • GLYPHOSATE

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1.33

Other Units: Litres/acre

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: unknown

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

-sprayed at 8:30 am, the winds were calm - tips used AI11003 at 10 US gallons per acre at 30 PSI

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

  • Skin
    • Symptom - Dermatitis

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

- Roundup was sprayed on a field. - a (Age) year old boy was waiting for the bus at the end of his lane - he was 15 to 20 feet from the edge of the field, then started to spray - mother took him into house, changed his clothes and washed him - then sent him to school - got home from school at around 4:00 pm and there was a rash on his neck - the doctor called it contact dermatitis - MOE tested and found roundup in the field but nothing on the grass along the lane

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The presence of skin irritation under these circumstances does not provide reliable evidence that transport and hence dermal exposure did, in fact, occur, particularly given that other attempts to demonstrate overspray (looking for damage to or residue on vegetation) have been negative.