Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4216

2. Registrant Information.

Registrant Reference Number: 120111014

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.

Domestic Animal

4. Date registrant was first informed of the incident.

11-SEP-12

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

08-AUG-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. 71995-33

Product Name: Roundup Weed and Grass Killer Ready To Use Plus

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
    • Guarantee/concentration 2 %

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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 III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

Rhodesian Ridgeback

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

110

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Trembling

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Seizure

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify unknown

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Rhodesian Ridgeback Dog (Canine Domestic) Signalment 10.0 yr intact female weighing 110.0 lb. Was in good health previously. Normal environment: indoors mostly. Patient Note [Note : No recent surgeries, medications, or known health problems. (Aug 08, 2012 at 10:31 PM)] Agent Exposures Roundup Weed and Grass Killer Ready To Use Plus (observed agent id) Evidence exposure occurred on Aug 08, 2012 at 06:00 PM CDT (possible ). Exposure involved 0.0 Not App (not specific) orally. The exposure was accidental, and occurred at animal owner garden. [Note : Exposure occurred at around 1600 CDT today. The dog was exposed to the product, it is unknown if the dog ingested the product. The owner noticed that Sadie is not wanting to move around a lot, avoiding people and shaking slightly. Sadie has also been having a very slimy diarrhea. The owner gave Sadie some milk and a 500mg Amoxicillin pill abut 30 minutes ago. The owner does not know is she is acting like this from an exposure or she is going into heat. (Aug 08, 2012 at 10:31 PM)] Amoxicillin Tablet 500 mg (Generic) (evidence agent id) Observed exposure occurred on Aug 08, 2012 at 10:10 PM CDT (observed ). Exposure involved 1.0 count (observed) orally. The exposure was treat condition, and occurred at animal owner home. The use was generally inapprop. Dosage Amoxicillin 10.021 mg/kg [Note : Owner gave one pill after the possible ingestion of Round Up. (Aug 08, 2012 at 10:31 PM)] Clinical Status Lethargy {Nervous} Begin: Aug 08, 2012 at 08:30 PM CDT Status: Moderate End: Aug 09, 2012 at 01:30 AM CDT Status: Death Trembling {General Disorders} Begin: Aug 08, 2012 at 08:30 PM CDT Status: Mild End: Aug 09, 2012 at 01:30 AM CDT Status: Death Diarrhea {Digestive} Begin: Aug 08, 2012 at 08:30 PM CDT Status: Moderate End: Aug 09, 2012 at 01:30 AM CDT Status: Death Seizure(s) {Nervous} Isolated Event: Aug 09, 2012 at 01:15 AM CDT15 min Status: Unknown Sudden Death {General Disorders} Permanent: Aug 09, 2012 at 01:30 AM CDT Status: Death The pet passed away following a seizure that occurred at 02:30 EST on August 9, 2012. The owner has buried the pet. Recommend the owner call the rDVM to make the clinic aware of the passing. Offered to provide the caller with assistance if she needed someone to speak with about the loss, she declined.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here