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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2249

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Country: 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: x

  • 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).

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

Information on crops located near the beeyards: corn was north/west from the beeyard, and was planted on 25 May.

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

Abnormal behavioural effects


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

There were a total of 150 colonies in the bee yard. There were 150 affected colonies. There were an average of <1 frames of bees, <2cm squared frames of brood, and >5 frames of pollen and honey. The following pests were present in the affected bee yard in the past year; American Foulbrood, Sacbrood, and Chalkbrood. Mite Away Quick Strips were applied at 2 per hive to treat varroa. Lack of foragers returning to hive. There were 0-500 dead bees observed per hive. no adult symptoms observed. Brood symptoms included overall decline in brood production. Queen symptoms included failure of colony to re-queen on its own, failure of purchased queen to establish. The weather at the time of the incident was sunny and moderate wind from the South, temperature was 27 C and humidity was average. The beekeeper does not know what the cause of the incident is. Samples of dead bees collected inside and outside the hives had positive detects coumaphos. Sample of pollen comb had positive detects for Thiamethoxam, clothianidin, imidacloprid and acetamiprid.

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