Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2011-3130

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 110072938

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.

13-JUL-11

5. Lieu de l'incident.

Pays: UNITED STATES

État: OKLAHOMA

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

08-JUN-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. 71995-33

Nom du produit: Roundup Weed and Grass Killer Ready To Use Plus

• 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: 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

Dog / Chien

3. Race

Havanese

4. Nombre d'animaux touchés

1

5. Sexe:

Homme

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

0.2

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

2

lbs

8. Voie(s) d'exposition:

Orale

9. Durée de l'exposition?

Unknown / Inconnu

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

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

• Système gastro-intestinal
  • Symptôme - Diarrhée
  • Symptôme - Vomit
  • Symptôme - Anorexie

• General
  • Symptôme - Mort

12. Quelle a été la durée des symptômes?

>3 days <=1 wk / >3 jours <=1 sem

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

Oui

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

Inconnu

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

Havanese Dog named [name] (Canine Domestic) Signalment 10.0 wk neutered male weighing 2.0 lb. Was in good health previously. Normal environment: indoors mostly. Agent Exposure Roundup Weed and Grass Killer Ready To Use Plus (observed agent id) Suspected exposure occurred on Jun 08, 2011 at 12:00 PM CDT¿6 hr (possible ). Exposure involved unknown amount orally. The exposure was accidental, and occurred at animal owner yard. [Note : Owner states that her husband had sprayed with this product on Wednesday and [name] had been out in the treated area that day. On Thursday, [name] began having some diarrhea and began vomiting. The owner states that [name] has not vomited since yesterday but has not been eating since Friday evening. She suspects that [name] licked up some of the product or ate a treated plant. (by [initials] on Jun 12, 2011 at 08:38 AM)] Because the amount was somewhat 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 : This product contains glyphosate. We could see mild and self-limiting GI upset (nausea, vomiting) from the surfactants in the product, if it was ingested while it was still wet. We would not expect to see any clinical signs from the active ingredient. (by [initial] on Jun 15, 2011 at 03:54 PM)] Clinical Status Diarrhea {Digestive} Time Observed: Jun 09, 2011 at 08:00 AM CDT Status: Mild Status: Unknown - [Note : accidentally entered. (by [initial] on Jun 15, 2011 at 04:23 PM)] End: Jun 12, 2011 at 05:00 PM CDT Status: Death Vomiting {Digestive} Time Observed: Jun 09, 2011 at 08:00 AM CDT Status: Moderate End: Jun 12, 2011 at 05:00 PM CDT Status: Death Anorexia {General Disorders} Time Observed: Jun 10, 2011 at 06:00 PM CDT Status: Moderate End: Jun 12, 2011 at 05:00 PM CDT Status: Death Death {General Disorders} Permanent: Jun 12, 2011 at 05:00 PM CDT Status: Death Potential Cause Roundup Weed and Grass Killer Ready To Use Plus Because the time course was poorly consistent, the amount was somewhat consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation. Patient Care Planned/Recommended Care Take Animal to Veterinarian Purpose: Other; Importance: Important Who: Owner ; Willingness: Willing Implemented Jun 12, 2011 10:00 AM Have Veterinarian Call for Information Purpose: Information; Importance: Important Who: Owner ; Willingness: Willing Refused, Reason: Unknown Call Back With Questions Purpose: Information; Importance: Important Who: Owner ; Willingness: Willing Refused, Reason: Unknown Unplanned Care Fluid Therapy Details: Performed Jun 12, 2011 10:00 AM , Effectiveness: Not Effective , use (Appropriate ) Outcome Died , EPA max illness designation: D-A [Note : Died 6/12 (by [initial] on Jun 15, 2011 at 04:23 PM)]

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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

List of Contacts Jun 12, 2011 at 08:38 AM CDT [name] (assistant) interacted with [name] (owner) for reason: obtain help. [Note : Advised per Dr. [name] that the Roundup can cause some GI upset if it is ingested when still wet. Signs are usually fairly mild though and would be expected to start within a couple hours of exposure. Based on what we are seeing from [name] it seems likely that this is not related to any exposure to the Roundup. Since he is so young and has not eaten since Friday evening we would want him to get to a DVM right away for evaluation and treatment. [name] could easily develop hypoglycemia and dehydration. The DVM can contact us for more information. Call back with any questions or concerns. (by [initial] on Jun 12, 2011 at 08:52 AM)] Jun 15, 2011 at 04:16 PM CDT [name] (assistant) for reason: monitor case-out. [Note : Called owner to update case. LMOM with case and follow up number asking owner to call back. (by [inital] on Jun 15, 2011 at 04:19 PM)] Jun 15, 2011 at 04:23 PM CDT [name] (assistant) interacted with [name] (owner) for reason: update case-in. [Note : O calling back with update. O took puppy to vet on 6/12 and was place on fluids. Puppy passed later that day. O refused further consultation with vet. (by [inital] on Jun 15, 2011 at 04:35 PM)]