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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5328

2. Registrant Information.

Registrant Reference Number: 32007418

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: CALIFORNIA

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).

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?


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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Muscle spasm
    • Symptom - Difficulty walking
    • Symptom - Difficulty walking
    • Specify - can no longer walk

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.)

Man calling is (age) years old, with a history of a traumatic brain injury in 2006 which has resulted in balance and equilibrium issues. He has difficulty walking which has worsened over the last year with increasing muscle spasms to the point he can no longer walk. His symptoms are similar to those of MS. He recently learned that the marijuana he had smoked 8 to 12 months ago had been killed with Roundup. He is now concerned that perhaps the smoked marijuana killed with the Roundup may have undergone some chemical changes when heated and exacerbated his symptoms. He does not have details of the type of Roundup used or how long after the actual plants were sprayed and killed that he was smoking the weed. MRPC discussed the product toxicity. The symptoms do not correspond with expected response to the product. The caller was still concerned about his exposure and unexplained exacerbation of his medical problems. MRPC discussed the case with Dr. (name), medical toxicolgist at Monsanto. Neurotoxicity is not expected. Products of combustion not expected to cause toxicity. The man was informed of the information per Dr. (name). To continue under the care of his current MD.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.