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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4484

2. Registrant Information.

Registrant Reference Number: 31996019

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

Unknown

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

• Active Ingredient(s)
  • GLYPHOSATE
    • Unknown

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 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Loss of appetite
  • Symptom - Weight loss

• Nervous and Muscular Systems
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom -
  • Specify - blood comes out when spitting

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

10. Route(s) of exposure.

Respiratory

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 that an unknown formulation of Roundup was sprayed on a weeded area and a bush area in his apartment complex for 2 days in a row. The caller states when he steps outside the door he's affected. He has had no direct exposure to the Roundup, but he walks by the sprayed areas. He states he cannot get the MSDS from the complex. No air conditioning in the apartment. The caller has a history of epilepsy and is a smoker. He states he has been having seizures everyday since the spraying. He is losing his appetite and has lost 6 pounds since last Thursday. When he spits, blood comes out of his esophagus. The caller states when he does not go on the property, he is fine. MRPC discussed the product toxicity. The symptoms do not correspond with expected response to the product. SPI concerned re: possible misinterpretation of symptoms and/or possible misidentification of product or mixed exposure. Advised the caller to seek medical attention and follow up with his MD.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Date of report was August 2nd, 2011. Subject is a smoker and already had a history of epilepsy prior to this incident and he has had no direct exposure to the Roundup.