Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1507

2. Registrant Information.

Registrant Reference Number: 2015-08

Registrant Name (Full Legal Name no abbreviations): MONSANTO CANADA INC.

Address: 180 KENT STREET, SUITE 810

City: OTTAWA

Prov / State: ONTARIO

Country: CANADA

Postal Code: K1R 0B6

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

15-APR-15

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

31-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 524-517

Product Name: Ranger Pro Herbicide

• Active Ingredient(s)
  • GLYPHOSATE
    • Guarantee/concentration 41 %

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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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Cancer
  • Specify - Diagnosed with cutaneous T cell Lymphoma but doctors are unsure

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Other

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

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.)

Caller states he has been using Ranger Pro as part of his job for 2 - 3 years. He was recently diagnosed with cutaneous T cell lymphoma but the doctors are unsure how to treat his symptoms and if it is even cancer. Caller states he uses 50 gallon tanks but dilutes 10 ounces of the Roundup per gallon (3.0%) and 4 ounces per gallon (1.25%) when using the backpack sprayer. He recalls being exposed to Roundup twice in the last 2 - 3 years both from the backpack leaking/malfunctioning. In one instance, he was using protective equipment but it soaked through the clothing. Caller states he continues to get unexplained rashes and nodules over his body.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.