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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5326

2. Registrant Information.

Registrant Reference Number: 32008021

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: CANADA

Prov / State: ALBERTA

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 Herbicide

• Active Ingredient(s)
  • GLYPHOSATE

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 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

• Skin
  • Symptom - Rash
  • Symptom - Peeling skin
  • Symptom - Blister
  • Symptom -
  • Specify - shingles

• Gastrointestinal System
  • Symptom - Mouth Irritation
  • Specify - blister inside mouth

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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

Unknown

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

Application

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

Unknown

10. Route(s) of exposure.

Skin

Oral

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 he used a Roundup concentrate grass and weed killer 3-4 months ago. He states that he diluted it properly based on the manufacturers instruction. While spraying, he got the product on his hands and he's pretty sure he then touched his mouth. The man states that about 2 months ago he started getting a rash on his hands and mouth. He says that the skin peeled off his hands and that he has blisters on the inside of his cheeks and on his lips. The man also stated he has shingles on his chest and back. MRPC discussed the product toxicity. The symptoms do not correlate with the expected response to the product. Advised to remain under the care of the MD.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.