Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2471

2. Registrant Information.

Registrant Reference Number: 2015-20

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.

Human

4. Date registrant was first informed of the incident.

10-JUN-15

5. Location of incident.

Country: UNITED STATES

Prov / State: UNKNOWN

6. Date incident was first observed.

Unknown

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. 264-789-524

Product Name: Acceleron IC-609

• Active Ingredient(s)
  • CLOTHIANIDIN
    • Guarantee/concentration 48 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 264-988-524

Product Name: Acceleron DC-509

• Active Ingredient(s)
  • IPCONAZOLE

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 264-989-524

Product Name: Acceleron DX-709

• Active Ingredient(s)
  • TRIFLOXYSTROBIN (CGA 279202)
    • Guarantee/concentration 22 %

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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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Pneumonia

• Blood
  • Symptom - Hypokalemia

• Gastrointestinal System
  • Symptom - Diarrhea

• Blood
  • Symptom - Other
  • Specify - Alkalosis

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Symptom - Other
  • Specify - rhabdomyolysis

• Blood
  • Symptom - Other
  • Specify - sepsis

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Occupational

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

Application

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

None

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.)

Seed Farmer inhaled Force insecticide which contains a pyrethroid. He was admitted to the hospital 5/12/15 with rhabdomyolysis, pneumonia, hypokalemia, possible sepsis and mild respiratory alkalosis. Man responded to to a dose of atropine leading to the suspicion, a substance he worked with was thought to be organophosphate.Toxicologist does not feel the time frame of symptoms after use of a pesticide adds up to organophosphate toxicity. Possible medical cause for symptoms as there was a recent fall in the bathroom. Farmer stated that he planted Roundup Ready corn and was never exposed to liquid seed treatments or any liquid chemicals.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.