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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-3009

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: x

  • Active Ingredient(s)

7. b) Type of formulation.

Other (specify)

seed treatment

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: seed treatment

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

corn planted with traditional corn seeder (split 4row/8row). The pesticide was applied as a seed treatment. Mite treatment in fall 2011 included Apistan, oxalic. Mite treatment in spring 2012 included formic 6 applications. Corn field to NE planted April 17 . Dekalb and Pioneer 35F38 treated with Cruiser Extreme 250 (thiamethoxam); dichlorprop-DX ground boom to w wheat. Winter wheat approx 250m away sprayed with Dichlorprop DX (dichlorprop-p and 2,4-D) on April 19. Wheat sample collected May 3. Treated with Apistan, oxalic Fall 2011; 6 apps of formic acid spring 2012. Bees seemed to recover after June21

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Terr. Invrtbrt-Honey Bee/Inv.Ter-Abeille

2. Common name(s)

3. Scientific name(s)

4. Number of organisms affected


5. Description of site where incident was observed

Fresh water



Salt Water

6. Check all symptoms that apply


7. Describe symptoms and outcome (died, recovered, etc.).

Bee mortality was observed on 2012-04-30 and was visited on 2012-05-03; a bee sample was collected on 2012-04-30,2012-05-02. There were 14 hives in the bee yard, with 7 hives showing mortality. The estimated number of dead bees was 50 to 100 per hive. The observed symptoms were death, it had been raining, in front of the colony. The state of the colony June 21, they seemed to recover .

8. a) Was the incident a result of (select all that apply)


8. b) i) How many times has the product been applied this year?


8. b) ii) What was the date of the last application?


9. Did it rain

9. a) During application?


9. b) Up to 3 days after application?


10. a) Was there a buffer zone?


10. b) What type?


10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?


To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here