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Incident Report
Subform I: General Information
1. Report Type.
Update the report
Incident Report Number: 2012-3019
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.
Environment
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
14-MAY-12Product 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.
Active(s)PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name: x
- Active Ingredient(s)
- CLOTHIANIDIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
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).
Mite treatment in fall 2011 included unknown. Mite treatment in spring 2012 included unknown. Dead beesTo be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
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
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Agricultural
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
Bee mortality was observed on 2012-05-14 and was visited on 2012-05-29; a bee sample was collected on 2012-05-18. There were 30 hives in the bee yard, with unknown hives showing mortality. The estimated number of dead bees was unknown. The observed symptoms were unknown. The state of the colony afterwards was unknown.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Yes
