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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-0580
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: QUEBEC
6. Date incident was first observed.
20-AUG-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. 30324 PMRA Submission No. EPA Registration No.
Product Name: Mite away quick strip
- Active Ingredient(s)
- FORMIC ACID
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1Other Units: pad
10. Site pesticide was applied to (select all that apply).
Site: Agricultural-Outdoor/Agricole-extérieur
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Mite away quick strip, 1/2 dose, un pad seulement au lieu de 2. Selon les directives du Fabricant NOD APIARIE INC.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)
Honey Bee
3. Scientific name(s)
Apis Mellifera
Unknown
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.).
1050 colonies/ruches. Mortalite de couvain opercule et couvain naissant. mortalite d'un % X de reines abeilles. Affaiblissement des colonies. Exposition au vapeur d'acide formic a de temperature exterieur de 25 - 28oC. Exposition de 72 heures au peak de liberation de l'acide formique.
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?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
