Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-2913
2. Registrant Information.
Registrant Reference Number: 130048372
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.
29-MAY-13
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
10-APR-13
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 71995-25
Product Name: Roundup Weed and Grass Killer Super Concentrate
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
- Guarantee/concentration 50 %
7. b) Type of formulation.
Liquid
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
8.0
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Anaphylactic shock
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Exposure was accidental and occurred in animal owner yard. The owner had sprayed this product in the yard on the afternoon of April 10th. The dog was tied up and kept out of the treated area until later that evening. On April 12th the dog vomited twice, had a normal bowel movement and then went into shock on the way to the RDVM. RDVM noted internal bleeding per the owner.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here