Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-3136

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: UNITED STATES

Prov / State: MINNESOTA

6. Date incident was first observed.

01-MAY-12

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.

Active(s)

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

Product Name: x

• Active Ingredient(s)
  • AZOXYSTROBIN
  • CLOTHIANIDIN
  • FLUDIOXONIL
  • THIABENDAZOLE
  • THIAMETHOXAM

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7. b) Type of formulation.

Other (specify)

seed treatmen

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: treated corn seed

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

Treated corn seed. The conditions at the time of planting were good seeding conditions, rain expected next day, 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?

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

Abnormal behavioural effects

Death

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

Bee mortality was observed on 2012-05-01 and was visited on 2012-05-03; a bee sample was collected unknown date. There were 1346 hives in the bee yard, with 1346 hives showing mortality. The estimated number of dead bees was unknown. The observed symptoms were crawling on ground unable to fly, trembling and twitching on backs and unable to right themselves. The state of the colony afterwards was unknown.Mite treatment in fall 2011 included unknown. Mite treatment in spring 2012 included unknown. gathered 2cups freshly dead or dying bees, 2cups of freshly gathered dandelion pollen from combs within the hives (efforts made to scrape off bright yellow pollen to ensure sample fresh recently gathered. Healthy bees were attempting to fly off with dead bees to get them further from the hive. One dead queen bee found and placed in sample. Pioneer corn P9630AM1 containing Liberty Link, Heculex XTRA, Poncho 1250, and Optimum Acre Max 1

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

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