Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-5696
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: NOVA SCOTIA
6. Date incident was first observed.
19-JUL-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:
- Active Ingredient(s)
- CARBOFURAN
- DIMETHOATE
7. b) Type of formulation.
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: Raspberry
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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)
Unknown
3. Scientific name(s)
Unknown
4. Number of organisms affected
2500
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.).
90 colonies of honeybees minimum of 2000 - 3000 bees in front of each colony. Dead bees in front of colony entrance. Bees died with tongues extended. Continued death. Shavings placed over dead bees in front of colony. Five hours later evidence of freshly killed bees in front of colony entrance.Dead bees in front of hive entrance. Collected by PMRA employee to be sent per analysis. Colonies had been moved to the location one week prior. Information provided by (name) (government department) (city) (province) (phone number) (e-mail address).
8. a) Was the incident a result of (select all that apply)
Application
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?
Terrestrial
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Yes
