Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2011-1233

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 100077305

Nom du titulaire (nom légal complet, aucune abbréviation): Monsanto Canada Inc.

Adresse: 180 Kent Street, Suite 810

Ville: Ottawa

État: ON

Pays: Canada

Code postal /Zip: K1P 0B6

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

16-JUL-10

5. Lieu de l'incident.

Pays: UNITED STATES

État: INDIANA

6. Date de la première observation de l'incident.

13-JUN-10

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 71995-33

Nom du produit: Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer

• Matière active
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
    • Garantie/concentration 2 %

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7. b) Type de formulation.

Liquide

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Pub. Area - Outdoor/Zone publique - ext

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Inconnu

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Autre

2.Type d'animal touché

Fish / Poisson

3. Race

Koi

4. Nombre d'animaux touchés

3

5. Sexe:

Inconnu

6. Âge (fournir un ordre de grandeur si nécessaire)

Inconnu

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Mort

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Spray drift / Dérive de pulvérisation

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

Signalment Age unknown Unknown weighing unknown amount. Normal environment: fresh water. Agent Exposure Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer (evidence agent id) Possible exposure occurred on Jun 13, 2010 at 09:07 AM CDT (suspected ). Exposure involved unknown amount by other route. The exposure was accidental, and occurred at public yard. [Note : Caller works at a medical office and they sprayed round up on their .The neighbors have a koi pond and 3 of the koi have died. The vet staff does not know what days the fish died. They sprayed the product on Sunday and the pond is 8-10ft from where they sprayed. There is a fence and vegetation in between the properties and the koi pond is up hill from where they sprayed. The caller does not know how many fish are in this pond. (by (name) on Jun 17, 2010 at 08:57 AM; amended by (name) on Jun 17, 2010 at 09:40 AM)] Because the amount was unknown consistent, the patient was considered to be at low risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening. [Note : The surfactant in Roundup can be toxic to fish. Because the pond is uphill to the application and it was not windy the day of the application it is unlikely the spraying is related to the fish deaths. (by (name) on Jun 17, 2010 at 10:25 AM)] Clinical Status Death (3) {General Disorders} [Note : The caller reports she knows that one fish died yesterday, but she does not know when the other fish died. (by (name) on Jun 17, 2010 at 09:40 AM)] Potential Cause Roundup Weed And Grass Killer Ready To Use Plus Pump N Go Sprayer Because the time course was poorly consistent, the amount was unknown consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation. Water Details: Have water quality checked Jun 17, 2010 at 09:40 AM CDT Holding, (name) (veterinarian) interacted with Angel (other caller) for reason: information. [Note : Called (name) back. Advised her that with the details of the exposure ( ie 8-10 feet away and uphill) it is unlikely that this would be related to the Roundup. (name) will be talking to the owner of the fish later today. Discussed the possibility that if it was a windy day with a heavy spray some of the product could have drifted to the pond. (by (name) on Jun 17, 2010 at 10:26 AM)] Jun 17, 2010 at 10:25 AM CDT Holding, (name) (veterinarian) interacted with (name) (other caller) for reason: information. [Note : (name) called to report that she talked to the person who applied the product. He reports he used a nozzle spray and the spray is very small. He also reported it was not windy the day of the application. She wanted to know if the spray were the cause of death wouldnt all the fish die. Discussed the case with Dr. (name) and we agreed given the details of the spraying it is highly unlikely the Roundup is related. With pesticide related deaths in a pond, how many die can depend on a wide variety of factors. The time frame of the death on the fish yesterday does not fit well with a reaction to Roundup. (by (name) on Jun 17, 2010 at 10:40 AM)] Jun 17, 2010 at 10:42 AM CDT (name) (toxicologist) interacted with Dr. (name) (other caller) , (name) (call center staff) for reason: obtain help. [Note : MD (name) calling with questions. (by (name) on Jun 17, 2010 at 10:47 AM)] [Note : Caller is a physician. Fish belong to the neighbor. Caller wanted to know if light use of roundup (ready to use) few feet away from the pond could have killed these fish? His neighbor thinks roundup killer the fish. This is about 60 gallon pond. It is highly unlikely that use of diluted roundup around the pond killed the fish. Hav eht eneighbot call back if they have any questions. (by (name) on Jun 17, 2010 at 10:47 AM)]

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À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici