Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-1453
2. Registrant Information.
Registrant Reference Number: 2015-07
Registrant Name (Full Legal Name no abbreviations): MONSANTO CANADA INC.
Address: 180 KENT STREET, SUITE 180
City: OTTAWA
Prov / State: ONTARIO
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.
14-APR-15
5. Location of incident.
Country: UNITED STATES
Prov / State: ALABAMA
6. Date incident was first observed.
24-MAR-15
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. 71995-51
Product Name: Roundup Max Control 365 1.33 GAL Wand
- Active Ingredient(s)
- DIQUAT
- Guarantee/concentration .04 %
- GLYPHOSATE
- Guarantee/concentration 1 %
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
Bird - Poultry / Oiseau - Volaille
3. Breed
Chickens
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller stated they used the Roundup five feet from chicken pen and chickens died. Caller disconnected phone before call could be transferred to the Poison Control Center. No other information is available. The number of chickens which died is unknown.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here