Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-3933

2. Registrant Information.

Registrant Reference Number: 2012-21

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.

27-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

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.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Roundup

• Active Ingredient(s)
  • GLYPHOSATE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

I recently used a premixed Roundup product in my yard, it was not windy, although there was the occasional breeze moving.

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.

Data Subject

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 - Rash

4. How long did the symptoms last?

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

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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)

None

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.)

The following email was sent from the Monsanto Canada 'Contact Us' webpage: I recently used a premixed Roundup product in my yard, it was not windy, although there was the occasional breeze moving. Unfortunately, I was not wearing long pants, just capri's and in the evening both my legs developed a spotted red rash which I'm assuming was a result of mist from the Roundup. I had no itching but there was a distinct burning sensation which persisted for two days. It will be one week tomorrow and the rash is still very visable but no more burning. Any info on line just said was the effected skin and discard the clothing. I'm wondering if this is more serious side effect of the product and if I should be seeing my physician (she's hard to get into so if I don't have to see her that would be great). I thank you in advance for any information you can provide me.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.