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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2277

2. Registrant Information.

Registrant Reference Number: xx

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: NOVA SCOTIA

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).

Too many fleids to list

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


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

There were a total of 8 colonies in the bee yard. There were 7 affected colonies and 1 dead colonies. There were an average of 40 frames of bees, 18 frames of brood, and 20 frames of pollen and honey. The following pests were present in the affected bee yard in the past year; varroa mite. Additional food sources provided to the bees included sugar syrup and pollen supplement (global 15% real pollen). In the begnning of Sept, Mite Away Quick Strips was applied at a rate of 2 strips to the hives to treat mites. At the end of Sept the antibotic fumagillian-B was applied to the hives at rate of 1 tsp of sugar syrup for 2g/colony, to treat nosema. Bees were actively foraging when questionnaire being filled out and after the adverse effects there was a noticeable decline in foraging. There were >2000 dead bees observed outside of each hive. no adult, brood or queen symptoms observed. Vrgin queen seen, did not observe old queen. The weather at the time of the incident was sunny. the bee incident occurred approx. 60 ft away from the hiv, the dead bees belonged to a swarm. The owner of the property noticed a small pile of bees when she left for work in the morning. By the end of the work day. The pile had become substantially bigger. the inspector was contacted and he collected as many bees as possible. when the inspector arrived, he observed another bunch of bees adjacent to the dead pile. He collected them in a hive and they are doing well and seem healthy. Samples of dead bees taken 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