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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3639

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: QUEBEC

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: unknown

  • 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: Unknown / Inconnu

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?


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)


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


Reproductive impairment

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

Au total, le rucher comptait 6 colonies. Il y avait 1 colonie touchée et 0 colonie morte. On a observé 0 - 500 abeilles mortes a l'extérieur de la ruche.Dans le cas des abeilles adultes, les symptômes comprenaient aggressivité et abeilles rampantes. De plus, hyperactivité. Dans le cas du couvain, les symptômes observés comprenaient les larves ou pupes mortes sur le plancher de la ruche. Dans le cas de la reine, les symptômes ne sont pas observés; les ruches pas ouvertes.L'échantillon d'abeille morte prélevés dans les ruches affectes a permis de détecter la présence de thiabendazole. Au moment de l'incident, les conditions météorologiques étaient Ensoleillé, environ 20C. Des sources supplémentaires d'aliments ont été fournies aux abeilles, y compris sirop de sucre. En 2012, on a effectué les traitements suivants aux ruches : acide oxalique et amitraze. Renseignements sur les cultures situées près des ruchers : 40 x 50 m de bluet (bio) situé à 5 m du rucher et mais situé à 1 km du rucher.

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