Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5597

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: xx

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

05-JUN-12

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.

Active(s)

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PMRA Registration No. 30324      PMRA Submission No.       EPA Registration No.

Product Name: MITE AWAY QUICK STRIPS

• Active Ingredient(s)
  • FORMIC ACID

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Bees

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

Le pesticide a ete applique tel que recommande par le fabriquant. C'est a dire deux sachets par colonie d'abeilles, soit un a l'avant et l'autre a l'arriere des cadres de la ruche. 120 ruches. Mite away Quick strips, acide formique en tube contre la varroase

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Death

Reproductive impairment

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

75% des reines sont mortes et les abeilles n'ont pas pu s'en refaire. Donc, une perte de 90 ruches. Dose deja dans les pochettes.

8. a) Was the incident a result of (select all that apply)

Application

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

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