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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-3014

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.

Application Information

8. Product was applied?


9. Application Rate.


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

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

corn planted. The conditions at the time of planting were unknown, and the crop was planted beyond 30m windbreak from the beeyard.Mite treatment in fall 2011 included unknown. Mite treatment in spring 2012 included unknown. As of June 21, 2012 fed twice, requeened, at three or four frames, well behind

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

Abnormal behavioural effects

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

Bee mortality was observed on 2012-04-26 and was visited on 2012-04-27; a bee sample was collected 2012-04-26,2012-04-27. There were 25 hives in the bee yard, with 4 hives showing mortality. The estimated number of dead bees was unknown. The observed symptoms were twitched, cant stand on their feet, in front of the hive, saw bees twitching well away the hive, four or five yards just won't move ahead and there was no noticeable damage - were they hit? - never gonna make any honey, quite a few with pollen on their legs, right in front of the legs. 4 stronger hives affected mostly. some twitching, noticed disoriented and dead bees. The state of the colony afterwards was As of June 21, 2012 fed twice, requeened, at three or four frames, well behind.

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