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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-5544
2. Registrant Information.
Registrant Reference Number: 2015-27
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.
08-OCT-155. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
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)PMRA Registration No. PMRA Submission No. EPA Registration No. 71995-33
Product Name: Roundup RTU Weed and Grass Killer III
- Active Ingredient(s)
- GLYPHOSATE
- Guarantee/concentration 2 %
- GLYPHOSATE
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 - Death
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
Unknown
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)
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.)
Coroner stated he is working on a case from (location) of a death. Man was found in his vehicle with two cups of milky white liquid on the console and a bottle of Roundup Weed and Grass Killer III in the trunk. Man had history of significant heart disease. Drug overdose is likely as man was on cardiovascular medications which can be significant. No other information was available.
To be determined by Registrant
14. Severity classification.
Death
