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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1065

2. Registrant Information.

Registrant Reference Number: 32041994

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: WEST VIRGINIA

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: Unknown

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

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: Industrial / Industriel

Préciser le type: Railroad

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burning skin
  • Symptom - Peeling skin

4. How long did the symptoms last?

>6 mos / > 6 mois

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)

Drift from the application site

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

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.)

Woman calls from (State) about her exposure to an unknown formulation of Roundup one year ago. She was sitting on (name) Street on a windy day when she noticed a misting on her face and skin. At the same time, the railroad was applying Roundup to the weeded areas on their property. She came home and and called the railroad office to see what they were using and was told 'Roundup' but no particular formulation. Caller mentioned she has already spoken to the poison center and national pesticide hotline to discuss all the symptoms possible with glyphosate/surfactant poisoning. She feels she was 'heavily sprayed' but showered within 1-2 hrs of the exposure when she got home. The only concern she offers is that her skin seems like it was 'burned' in several places and has been peeling. MRPC discussed the product toxicity. The symptoms do not correlate with the expected response to the product. Advised to express concern for symptoms with her physician to aid in diagnosis.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.