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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3134

2. Registrant Information.

Registrant Reference Number: 31984260

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: FLORIDA

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. 524-445

Product Name: Roundup Herbicide

  • Active Ingredient(s)
      • Guarantee/concentration 41 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Unknown / Inconnu

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

diluted the Roundup 2 quarts in 25 gallons of water

To be determined by Registrant

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


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

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Bronchitis
    • Symptom - Nose bleed
    • Symptom - Pneumonia
    • Symptom - Bronchospasm
  • General
    • Symptom - Fever
  • Respiratory System
    • Symptom - Difficulty Breathing

4. How long did the symptoms last?

>6 mos / > 6 mois

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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


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


10. Route(s) of exposure.


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.)

Caller states her spouse was exposed to the spray of Roundup when the wind shifted during spraying about 1 year ago. No mask was worn. No calls to the MRPC at the time of the exposure. He has had problems with his breathing and nose bleeds since then. The man bathed after the exposure. He had diluted the Roundup 2 quarts in 25 gallons of water. Since that time he has had bronchitis. 15 days later he had a nose bleed that bled 5-6 times/day for over a week. The man has a long standing history of nose bleeds since childhood. The ENT MD performed a cauterization. He remained flat on his back for several weeks using nasal gel and antibiotics. About 6-7 wks ago, the man became ill and went to the MD and was given levaquin for treatment of pnuemonia, although his lungs were clear. He got better, when the levaquin ran out, his symptoms got worse. He was given prednisone and cough syrup for bronchospasm. His lungs are clear per CXR. When the steroid was gone he got worse again. He is now seeing a pulmonary specialist and given more antibiotics and now has a fever. MRPC discussed the product toxicity. The symtpoms do not correlate with the expected response to the product. Remain under the care of MD. MRPC is available to speak with MD if desired.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.