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Adverse Effects User Submission Form
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Country
*
Please Select
Argentina
Australia
Austria
Brazil
Bulgaria
Canada
China
Colombia
Denmark
Estonia
Finland
Germany
Greece
Ireland
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Latvia
Lithuania
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New Zealand
Pakistan
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Romania
South Africa
Spain
Sweden
Switzerland
Turkey
Ukraine
United Kingdom
United States
Other
State
*
Please Select
Corteva Product Name
*
Date of Exposure
*
Type of Exposure
*
Human
Domestic Animal
Plant Damage
Fish or Wildlife
Water Contamination (e.g. drinking water, surface water, groundwater)
Other Non-targer Organism (e.g., beneficial insects)
Property Damage
Packaging Failure
Other
If other, describe exposure type
*
Route of Exposure
*
Eye/Occular
Ingestion/Oral
Inhalation/Respiratory
Skin/Dermal
Unknown
NA
For HUMAN exposure, please provide the following information
Age
*
Gender
*
Was medical treatment received? If yes, what treatment was provided?
*
For DOMEST ANIMAL exposure (e.g., dog, cat, cow, horse, chicken, etc.), please provide the following information
Type of Animal
*
Number of Animals Affected
*
Was veterinary treatment received? If yes, what treatment was provided?
*
For FISH of WILDLIFE exposure, please provide the following information
Species Affected
*
*
If OTHER exposure, please provide the following information
Type of Non-target organism (bees, butterflies, ladybugs)
*
Number Affected
*
If WATER exposure, please provide the following information
Type of Water (drinking, ground, surface)
*
Amount Affected
*
If PLANT DAMAGE, please provide the following information
Plant Type
*
Number Exposed (number of plants, acres, hectares etc exposed to the product)
*
Number Affected (number of plants, acres, hectares, etc showing symptomology)
*
Provide Brief Description of Circumstances
*
List symptoms (if any) from exposure. Type N/A if no symptoms
*
Consent to process the personal information
*
Consent to process the sensitive personal information
*
Consent to transfer the personal and sensitive personal information to a party located outside of your country (including Corteva’s oversea subsidiary companies and other unaffiliated parties located outside of your country in accordance with this Notice.
*
Submit
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