Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-3119

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).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: wheat

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

cereal crops planted with unknown product. The pesticide was applied to: wheat MAY have been sprayed Apr 20. The conditions at the time of planting were: in general has been cool, dry, windy, and the crop was planted unknown distance from the beeyard.

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 on 2012-04-27. There were 29 hives in the bee yard, with 28 hives showing mortality. The estimated number of dead bees was: noticed about a kilo of dead bees. The observed symptoms were: laying on their back, still twitching some had a bit of pollen on their legs, in front of the colony. Some twitching. Only dead bees observed outside of hives. Laying on their back, still twitching, some had a bit of pollen on their legs, in front of the colony. The state of the colony afterwards was: as of June 21,2012, the colonies are starting to come back - back where they should be.Mite treatment in fall 2011 included Apivar. Mite treatment in spring 2012 included MAQS. Treated with APIVAR Fall 2011 and MAQS spring 2012. As of June 21, 2012, the colonies are starting to come back - back where they should be.

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