Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-3225

2. Registrant Information.

Registrant Reference Number: CTVA240627

Registrant Name (Full Legal Name no abbreviations): Corteva Agriscience Canada Company

Address: Suite 240, 115 Quarry Park Road S.E.

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T3C 5G9

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

Human

4. Date registrant was first informed of the incident.

15-MAY-24

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

Unknown

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)

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Chlorpyrifos

• Active Ingredient(s)
  • CHLORPYRIFOS
    • Unknown

---

7. b) Type of formulation.

Liquid

Other (specify)

POWDER

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

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

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Other
  • Specify - Heart damage

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Developmental deficits
  • Symptom - Other
  • Specify - Nerve Damage
  • Symptom - Other
  • Specify - PTSD
  • Symptom - Muscle tremors
  • Symptom - Muscle twitching
  • Specify - Twitching of the nerves
  • Symptom - Other
  • Specify - Brain damage
  • Symptom - Other
  • Specify - ADHD
  • Symptom - Anxiety

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

Callers original reason for calling was to obtain an email to send his medical documentation to.Consumer stated he lived in the middle of many orchards in California also known as the Fruit Basketof the world from 1983 to 1990. Caller stated during that time he was exposed to the product in liquidand powder form from all of the orchards around him. He stated he had many trips to the doctor due topesticide poisoning. Caller stated during that era they did not take that sort of diagnosis seriously. Hestated that through the years his life fell apart having symptoms of tremors, twitching of the nerves,nerve damage, heart damage, brain damage, PTSD, Attention Deficit Hyperactivity Disorder, Anxiety,neurological damage, and developmental deficits all due to being exposed to the product in multipleforms during those years. Caller stated due to all of the symptoms he experiences because of the exposure to the product for so many years, he has been homeless, failed in classes, and his daughter being born in 1992 with some of the same issues brain damage being the only one named during theconversation. Caller stated being exposed to the product has ruined his whole life.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Consumer stated after years of doctors visits he came to the conclusion that the product was the cause of his ongoing symptoms. It is not clear how the consumer has connected his exposure to this manufacturer. When asked consumer denied having any product information, labels, etc. He only had the name of the product.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Brain Damage

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

daughter being born in 1992 with some of the same issues, brain damage being the only one named during the conversation.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

No additional information provided