Adverse Effects User Submission Form

First Name *

Last Name *

Phone Number *

Email Address *

Country *

Argentina
Australia
Austria
Brazil
Bulgaria
Canada
China
Colombia
Denmark
Estonia
Finland
Germany
Greece
Ireland
Japan
Latvia
Lithuania
Malaysia
Mexico
Moldova
New Zealand
Pakistan
Poland
Portugal
Romania
South Africa
Spain
Sweden
Switzerland
Turkey
Ukraine
United Kingdom
United States

State *

Corteva Product Name *

Date of Exposure *

Provide Brief Description of Circumstances *

List symptoms (if any) from exposure. Type N/A if no symptoms *

Consent declaration: I have read and fully understand the terms and conditions of the consent notice and by checking the checkbox, I give my free, prior, informed, and express consent. *

Submit

By clicking "Submit," I hereby consent to the collection and processing of personal information, including sensitive personal information such information is provided by me, as stated in the Privacy Notice, including the transfer of my personal Information to the United States.