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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2257

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: 80ha and 50ha of corn was 5m North and east from the beeyard. Seed treated. Planted, not yet emerged

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


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

There were a total of 22 (18 at time of incident) colonies in the bee yard. There were 14 affected colonies which died 14. There were an average of 3 frames of bees, 2 frames of brood, and 2 frames of pollen and honey. No pests present in the affected bee yard in the past year. Additional food sources provided to the bees included high fructose. In Sept/Oct 2013 (strips still in hives), Mite Wipes, Formic Acid, and Apivar was applied at to the hives. large amount of dead bees in front of hives. There were >2000 dead bees observed inside and oustide of each hive. no adult symptoms observed, bees found dead. The weather at the time of the incident was overcast and average temperature. Bee Keeper does not know what was the cause of the incident. Sample of dead bees taken had positive detects for Coumaphos. Samples of comb pollen had positive detects for clothianidin and Imidacloprid and the soil (from corn field) had thiamethoxam and clothianidin. A second sample of dead bees taken had no detected active ingredients.

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