Apiary Pesticide Exposure Report
Reporter Information
Name
Contact (Email/Phone)
Affiliation
Apiary Information
Location
Apiary ID/Name
Number of Hives Affected
Incident Details
Date Discovered
Suspected Date of Exposure
Symptoms Observed
Estimated Bee Loss/Impact
Pesticide Information
Suspected Pesticide(s) Name
Application Method (e.g. aerial, ground)
Nearby Treated Crop(s)
Evidence (e.g. residue, containers, local activity)
Additional Notes