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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-1801

2. Registrant Information.

Registrant Reference Number: 32132018

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: HAWAII

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. 524-549

Product Name: Roundup PowerMAX

  • Active Ingredient(s)
      • Guarantee/concentration 50 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Unknown / Inconnu

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

The caller had been spraying Roundup PowerMAX. He used a lawn mower sprayer that was hooked to the back of the lawn mower.

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.


  • Cardiovascular System
    • Symptom - Cardiac arrest
  • Skin
    • Symptom - Flushed
    • Specify - Hot flushes
    • Symptom - Irritated skin

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.


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.

>24 hrs <=3 days / >24 h <=3 jours

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.)

He states he had a recent heart attack 7 days ago and wants to know if the herbicide caused it. The caller had been spraying Roundup PowerMAX for 2 days before the heart attack. He used a lawn mower sprayer that was hooked to the back of the lawn mower. He reports having hot flashes or nerve flashes 1 week before the heart attack. The nerve flashes felt like needles and irritation moving all over the body from the ankle then to his arm then to his ribs. MRPC discussed the product toxicity. The symptoms do not correspond to the expected response to the product. Advised to remain under the care of his MD. MRPC is available to answer questions if MD desires.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Early symptoms in form of hot flushes or nerve flashes and irritation all over the body from ankle to his arm seem to have been present at least 5 days before he used the product.