Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3666

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: 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)


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


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

There were was no affected Bee Colony information. There was no foraging information. There was no adult Bee Symptoms information. There was no Brood Symptoms information. There was no queen symptoms information.The weather at the time of the incident was unknown. Prior to the incident, the average frames of bees, the average frames of brood, and the average frames of pollen and honey are all unknown. It is unknown if the pests were present in the affected bee yard in the past year. The general health of the affected bee yard after the case was unknown. The treatment details for 2012 was unknown. The treatment details for 2013 was unknown. The treatment details with a date unknown had no data.The information on crops located near the affected bee hives was unknown. Inspection Notes: lots of dead bees, outside hives (workers not drones). For this time of year, some drones oustide is normal. At least 2-3 cups in front of worst hive. All hives have some dead bees out frong. Hive 3: 9 mites HIGH for this time of year (upper threshold). Unknown mite treatment. Most affected hive. Hive 6: least affected, less than 10 dead bees out front. 5 mites/300 bees (average for fall).

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