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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3133

2. Registrant Information.

Registrant Reference Number: 110079269

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-JUL-11

5. Location of incident.

Country: UNITED STATES

Prov / State: IDAHO

6. Date incident was first observed.

22-JUN-11

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. 71995-33

Product Name: Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
      • Guarantee/concentration 2 %

7. b) Type of formulation.

Liquid

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

King Charles

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

23

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

  • General
    • Symptom - Death
  • Blood
    • Symptom - Bleeding
    • Specify - blood coming from mouth

12. How long did the symptoms last?

Unknown / Inconnu

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

No

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?

Other / Autre

specify unknown

17. Provide any additional details about the incident

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

Canine Domestic Unspecified named [name] (Canine Domestic) Signalment 4.0 yr neutered female weighing 23.0 lb. Was in excellent health previously. Normal environment: indoors mostly. Agent Exposure Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer (observed agent id) Possible exposure occurred on Jun 22, 2011 at 05:00 PM CDT (possible ). Exposure involved 0.0 Not App (not specific) by unknown route. The exposure was accidental, and occurred at animal owner yard. [Note : The owner's children sprayed the agent around the house and then left the product inside the house with the dog. The owner left the house and came back 1 hour later to find the dog dead with blood coming out of its mouth. (by [initials] on Jun 24, 2011 at 07:37 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. [Note : Glyphosate has a very wide margin of safety. It inhibits a specific biochemical pathway that is unique to plants. Ingestion of the product when wet can cause some irritation to the oral mucous membranes, causing nausea and vomiting. Once the product has dried and is absorbed into the plants it is nontoxic. (by [initials] on Jun 28, 2011 at 08:38 PM)] Clinical Status Death {General Disorders} Permanent: Jun 22, 2011 at 06:00 PM CDT Status: Death Potential Cause Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer Because the time course was not 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. Patient Care Planned/Recommended Care Necropsy Purpose: Diagnostic; Importance: Important Who: Owner ; Willingness: Willing Recommended Details: At DVM clinic if the owner is looking for cause of death [Note : Owner claimed that the dog was a King Charles Sitting Dog but not a Cavalier King Charles Spaniel (by [name] on Jun 24, 2011 at 07:37 PM)] Outcome Died , EPA max illness designation: D-A List of Contacts Jun 24, 2011 at 07:37 PM CDT [name] (assistant) interacted with [name] (owner) for reason: obtain help. [Note : Owner is calling to obtain help. Per Dr. [name], we would not expect to see bleeding or death from an exposure to this agent. If we were to see any signs from this agent it would be mild, self limiting GI upset. The owner can contact her DVM about doing a necropsy if she is trying to figure out what did cause her dog's death. (by [initials] on Jun 28, 2011 at 08:39 PM)]


To be determined by Registrant

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

Death

19. Provide supplemental information here