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: 2015-2251

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: Soybean was west of the beeyard, and was planted on 2014-05-28. [DY] was used on the crop. Planting occurred in area yesterday + today (may 28). Wheat and alfalfa to the East of bee yard. Alfalfa and emergency soybean to the West of bee yard (refer to diagram). Not aware of any new plantings adjacent to hives.

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.).

There were a total of 4.5 colonies in the bee yard. There were 4.5 affected colonies. There were solid (full) frames of bees, lots of brood and not much honey yet. Additional food sources provided to the bees included honey. In the fall and this spring (just removed them), formic acid was applied to the hives. the bees were Actively foraging when incident occurred; actively foraging when questionnaire being filled out. there were about 200 dead bees per colony over a 3 hour time period, the dead bees were located outside the hive. Adult bee symptoms included shaking/trembling/twitiching, crawling, disoriented. Brood symptoms included dead larvaw/pupae on bottom board. no queen symptoms observed. The weather at the time of the incident was sunny and fairly breezy (Northwest), temperature was 22 C and humidity was average. The Last rain event occurred one week ago. Bee keeper believes neonictinoid poisoning was the cause of the incident. Sample of dead bees had positive detects for clothianidin.

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