Health Canada
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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5575

2. Registrant Information.

Registrant Reference Number: 2011-26

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.

Country: CANADA

Prov / State: UNKNOWN

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. Unknown

Product Name: Roundup Concentrate

  • Active Ingredient(s)

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: Res. - Out Home / Rés - à l'

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Lesion
    • Specify - Red welts
    • Symptom - Red skin
    • Symptom - Other
    • Specify - rough skin
  • Respiratory System
    • Symptom - Runny nose
  • Eye
    • Symptom - Burning eye

4. How long did the symptoms last?

Unknown / Inconnu

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.

>24 hrs <=3 days / >24 h <=3 jours

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.)

June 20 cust bought round up for the crack in her double driveway (due to weeds). Cust adv she sprayed the driveway but it "seeped" into her garden (vegetables) and grass. She was getting red welts due to intoxication of round up (as per # health Canada), she had been walking on the grass and this is how it started. She thinks she may have ingested this. She went to clinic and they had to give her tetanus shot, antibiotics and use cream to get rid of this. Cust is looking for compensation for what she has been through. She doesn't have product or receipt, but adv that Health Canada says it is illegal in Quebec.? Cust called me to advise that she does not have the receipt with prod # but initially purchased the 5L Roundup "Pump and Go" for $39.99, it did not get rid of all her weeds so she purchased the concentrated for $29.99 which was to be mixed with water. Cust adv'd that 2-3 days later, her hands were red, rough and had little bumps or welts on them. She went to the clinic, they gave her meds. She then watered her property for 3 days in order to get rid of the Roundup. Cust adv'd that she also notices her feet and legs were red and rough. Since then she has had problems with runny nose, burning eyes, etc. Doctor has adv'd that the prod intoxicated her and she has had to purchase more meds since then. Cust also would like to be compensated for her soil, manure, vegetables lost due to this concern. I asked cust to retain all receipts, thanked the cust for the info and adv'd that I would forward her file to insurance for investigation. Cust thanked me.?

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.