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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1470

2. Registrant Information.

Registrant Reference Number: 32048091

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: ILLINOIS

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)
    • 2,4-D (PRESENT AS ACID)
      • 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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - Other
    • Specify - ill

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.

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 the MRPC stating he would like to see a toxicologist and is looking for a recommendation. He states he has a severe poisoning from herbicides and pesticides from months of inhalation less than 2 years ago. He had been to his doctor a number of times since then with 'a couple of hundred tests ordered'. His doctor, in (city, state), recommended he see a toxicologist for further help. He feels his exposure was to glyphosate, 2,4D and formoxin (will not spell it, then spoke of surfactants and mixtures with the herbicide). He saw a man spraying the pesticides on his trees which died. He inhaled the products when they were being applied and was re-exposed while mowing grass. Recently, his cholinesterase level was checked. The man states he has never been sick in his whole life and now he is ill. He refused to discuss specific symptoms. MRPC discussed the product toxicity and advised that systemic symptoms that are chronic or delayed onset in nature do not correlate with the expected response to the product. It was difficut to assess if the man was actually exposed and to what degree. MRPC questions if the man may have a medical or psychological explanation for his undisclosed problem. The man hung up refusing to give his name. Later in the day, the man called back asking how to make an appointment with a toxicologist. He states he has been calling various state's poison control centers and is calling from (city, state). He does not specify what substance he has been exposed to, but feels that the reason his PMD has not been helpful is 'corruption' that also is preventing him from making an appointment with a poison specialist. The MRPC provided a telephone number to a MD toxicologist in (city, state),who he might be able to set an appointment to be seen. The man states he got that name from the (state) Poison Control Center but with a different phone number but he will try it.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.