Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2011-3499

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 110085240

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.

11-AUG-11

5. Lieu de l'incident.

Pays: UNITED STATES

État: TENNESSEE

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

22-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

Chihuahua

4. Nombre d'animaux touchés

2

5. Sexe:

Homme

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

0.17

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

2

lbs

8. Voie(s) d'exposition:

Cutanée

9. Durée de l'exposition?

Unknown / Inconnu

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

>24 hrs <=3 days / >24 h <=3 jours

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Lethargie

• Système gastro-intestinal
  • Symptôme - Anorexie

• General
  • Symptôme - Mort
  • Symptôme - Adipsie

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

Signalment 8.0 wk immature male weighing 2.0 lb. Was in good health previously. Normal environment: indoors mostly. Agent Exposures Roundup Weed and Grass Killer Ready To Use Plus (evidence agent id) Suspected exposure occurred on Jun 22, 2011 at 12:00 PM CDT (evidence ). Exposure involved 0.0 Not App (not specific) dermally and orally. The exposure was accidental, and occurred at animal owner yard. [Note : Owner states he had a litter of chihuahuas that he was raising to sell. Around 6/22 he had sprayed around a fence in his yard with the roundup product. After 30-45 minutes he let the dogs outside into the yard and treated area. Roughly 2 days later, on 6/24, he saw one of the puppies become lethargic and did not want to eat and drink. He started giving pepto bismol twice daily and estimates that the doses were 1 oz but is not certain. The next day, a second puppy starting showing signs as well and the following day, 6/26, the first puppy had died. The second puppy did not improve at all and just died yesterday. As of today the last puppy is now starting to show the same signs. The owner suspects that this is all from exposure to the roundup. (by JG on Jul 06, 2011 at 10:04 AM)] Because the amount was poorly 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 : Exposure to a wet product can cause mild transient gi upset. Serious toxicity or death are not expected. (by IM on Jul 08, 2011 at 10:02 AM)] Clinical Status Lethargy {Nervous} Time Observed: Jul 06, 2011 at 08:00 AM CDT¿6 hr Status: Moderate Anorexia {General Disorders} Time Observed: Jul 06, 2011 at 08:00 AM CDT¿6 hr Status: Mild Potential Causes Roundup Weed and Grass Killer Ready To Use Plus Because the time course was somewhat consistent, the amount was poorly consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation. Pepto Bismol Original Liquid Bismuth Subsalicylate 262 mg Per 15 mL Because the time course was somewhat consistent, the amount was generally consistent, and the findings were somewhat consistent, this substance was considered to have low likelihood of causing the clinical situation.

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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 3 dogs involved in this incident, however only 2 of them died. Therefore only 2 dogs were entered into this incident report.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Autre

2.Type d'animal touché

Dog / Chien

3. Race

Chihuahua

4. Nombre d'animaux touchés

1

5. Sexe:

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

0.17

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

2

lbs

8. Voie(s) d'exposition:

Cutanée

9. Durée de l'exposition?

Unknown / Inconnu

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

>24 hrs <=3 days / >24 h <=3 jours

11. Énumérer tous les symptômes

Système

• General
  • Symptôme - Lethargie

• Système gastro-intestinal
  • Symptôme - Anorexie

• General
  • Symptôme - Adipsie

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

Unknown/Inconnu

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

Signalment 8.0 wk immature male weighing 2.0 lb. Was in good health previously. Normal environment: indoors mostly. Agent Exposures Roundup Weed and Grass Killer Ready To Use Plus (evidence agent id) Suspected exposure occurred on Jun 22, 2011 at 12:00 PM CDT (evidence ). Exposure involved 0.0 Not App (not specific) dermally and orally. The exposure was accidental, and occurred at animal owner yard. [Note : Owner states he had a litter of chihuahuas that he was raising to sell. Around 6/22 he had sprayed around a fence in his yard with the roundup product. After 30-45 minutes he let the dogs outside into the yard and treated area. Roughly 2 days later, on 6/24, he saw one of the puppies become lethargic and did not want to eat and drink. He started giving pepto bismol twice daily and estimates that the doses were 1 oz but is not certain. The next day, a second puppy starting showing signs as well and the following day, 6/26, the first puppy had died. The second puppy did not improve at all and just died yesterday. As of today the last puppy is now starting to show the same signs. The owner suspects that this is all from exposure to the roundup. (by JG on Jul 06, 2011 at 10:04 AM)] Because the amount was poorly 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 : Exposure to a wet product can cause mild transient gi upset. Serious toxicity or death are not expected. (by IM on Jul 08, 2011 at 10:02 AM)] Clinical Status Lethargy {Nervous} Time Observed: Jul 06, 2011 at 08:00 AM CDT¿6 hr Status: Moderate Anorexia {General Disorders} Time Observed: Jul 06, 2011 at 08:00 AM CDT¿6 hr Status: Mild Potential Causes Roundup Weed and Grass Killer Ready To Use Plus Because the time course was somewhat consistent, the amount was poorly consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation. Pepto Bismol Original Liquid Bismuth Subsalicylate 262 mg Per 15 mL Because the time course was somewhat consistent, the amount was generally consistent, and the findings were somewhat consistent, this substance was considered to have low likelihood of causing the clinical situation.

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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)

Mineure

19. Donner des renseignements additionnels ici