Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2011-2962

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 110033137

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.

15-APR-11

5. Lieu de l'incident.

Pays: UNITED STATES

État: CALIFORNIA

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

19-MAR-11

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. 71995-40

Nom du produit: Roundup Concentrate Extended Control Weed And Grass Killer Plus Weed P

• Matière active
  • DIQUAT, PRESENT AS DIBROMIDE
    • Garantie/concentration .73 %
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
    • Garantie/concentration 18 %

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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: Res. - Out Home / Rés - à l'ext.maison

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

Cat / Chat

3. Race

unknown

4. Nombre d'animaux touchés

1

5. Sexe:

Homme

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

0.75

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?

Persisted until death

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?

Contact treat.area/Contact surf. traitée

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

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

Feline Domestic Unspecified Mix named (name) (Feline Domestic) Signalment 9.0 mo neutered male weighing unknown amount. Was in good health previously. Normal environment: outdoors mostly. Agent Exposure Roundup Concentrate Extended Control Weed And Grass Killer Plus Weed Preventer (not specific agent id) Possible exposure occurred on Mar 19, 2011 at 12:00 PM CDT (suspected ). Exposure involved unknown amount by unknown route. The exposure was accidental, and occurred at animal owner yard. [Note : The owner sprayed the product in her yard yesterday. (name) was in the area when she sprayed and would not leave. The owner came out to her driveway today and moved her car a few inches farther under the carport. She she was done, she saw the cat under the car dead (she did not run him over). The other cat in her household is asymptomatic. (by on Mar 20, 2011 at 02:58 PM)] 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 : Glyphosate has a very wide margin of safety. It inhibits a specific biochemical pathway that is unique to plants. Ingestion of the product when wet can cause some irritation to the oral mucous membranes, causing nausea and vomiting. Once the product has dried and is absorbed into the plants it is nontoxic. (by on Mar 21, 2011 at 11:16 AM)] Clinical Status Death {General Disorders} Permanent: Mar 20, 2011 at 12:00 PM CDT Status: Death Potential Cause Roundup Concentrate Extended Control Weed And Grass Killer Plus Weed Preventer Because the time course was not consistent, the amount was unknown consistent, and the findings were not consistent, this substance was considered to have not related likelihood of causing the clinical situation. Patient Care Planned/Recommended Care Necropsy Purpose: Diagnostic; Importance: Important Who: Owner ; Willingness: Unwilling Refused, Reason: Uncataloged reason Outcome Died , EPA max illness designation: D-A Feline Domestic Unspecified Mix named Princess (Feline Domestic) Signalment 9.0 mo neutered female weighing unknown amount. Was in good health previously. Normal environment: outdoors mostly. Patient Note [Note : Princess is not showing any signs of illness at this time. (by on Mar 21, 2011 at 11:16 AM)] Agent Exposure Roundup Concentrate Extended Control Weed And Grass Killer Plus Weed Preventer (not specific agent id) Possible exposure occurred on Mar 19, 2011 at 12:00 PM CDT (suspected ). Exposure involved unknown amount by unknown route. The exposure was accidental, and occurred at animal owner yard. [Note : The owner sprayed the product in her yard yesterday. (name) was in the area when she sprayed and would not leave. The owner came out to her driveway today and moved her car a few inches farther under the carport. She she was done, she saw the cat under the car dead (she did not run him over). The other cat in her household is asymptomatic. (by on Mar 20, 2011 at 02:58 PM)] 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 : Glyphosate has a very wide margin of safety. It inhibits a specific biochemical pathway that is unique to plants. Ingestion of the product when wet can cause some irritation to the oral mucous membranes, causing nausea and vomiting. Once the product has dried and is absorbed into the plants it is nontoxic. (by on Mar 21, 2011 at 11:16 AM)] Potential Cause Roundup Concentrate Extended Control Weed And Grass Killer Plus Weed Preventer Because the time course was unknown consistent, the amount was unknown consistent, and the findings were unknown consistent, this substance was considered to have did not monitor likelihood of causing the clinical situation. Patient Care Planned/Recommended Ca

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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

There were 2 cats reported on in this case, however only 1 was reported to have died. The other cat's outcome is unknown. Therefore only one cat was entered in this report.