Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4644

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

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: ONTARIO

6. Date incident was first observed.

07-JUN-14

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.       PMRA Submission No.       EPA Registration No.

Product Name: Roundup

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: soybean

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

1. Field adjacent to east side of XXXXXX and north of XXXXXX (planted in soybeans), and 2. Field adjacent to west side of XXXXXX and south of XXXXXX (planted in soybeans), And believes the spray may be linked to the decline in honey bees foraging his wild flowers. Note - also, field adjacent to east side of XXXXXX and south of XXXXXX had been recently planted in soybeans. He indicated they have applied two sprays this season, both post-emergant Round-up applications without any insecticide tank mixes, for the control of weeds. (Round-up has no known acute toxicity to honey bees). Farm has about 3,600 acres planted this season, with the majority of lands planted with soybeans.

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

Abnormal behavioural effects

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

And believes the spray may be linked to the decline in honey bees foraging his wild flowers.

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

Unknown

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?

No

9. b) Up to 3 days after application?

No

10. a) Was there a buffer zone?

No

10. b) What type?

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

11. a) Were environmental samples collected and analysed?

No

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

Minor

13. Please provide supplemental information here