Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-3650

2. Registrant Information.

Registrant Reference Number: 32086115

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.

02-AUG-12

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

13-JUL-12

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.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 524-445

Product Name: Roundup

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

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

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?

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

• Respiratory System
  • Symptom - Difficulty Breathing
  • Specify - breathing problems
  • Symptom - Respiratory distress
  • Specify - COPD

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

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

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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 a family member has been sick for about a week with breathing problems. He has been to the hospital and had prednisone and other drugs prescribed without improvement. COPD was diagnosed. The man has had some breathing issues in the past, but his symptoms got worse suddenly and quickly. About a week or two ago, the man accidentally got an unknown concentrate Roundup, diluted for use, on his skin. It splashed over the front of him and his face. He took a shower immediately. His symptoms began about one week later. No known cough or choke at the time and no other symptoms noted at the time of the exposure. MRPC discussed the product toxicity. The symptoms do not correlate with the expected response to the product. Advised to continue under the care of MD.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.