APPENDIX B - Sample Forms, Fact Sheets, and Checklists

Appendix B includes a sample Application List form with space for all the pesticide application information the WPS requires to be listed at a central location on each agricultural establishment. The WPS does not specify a format for presenting the information-you may copy this form or design another that meets your needs.

Appendix B also includes several fact sheets to help you comply with sections of the WPS that require you to provide information to others. Although the WPS does not require you to provide this information in written form, you may find that using photocopies of these fact sheets is a convenient way to make sure you convey all the necessary information. Finally, Appendix B includes some checklists you can use as reminders of your WPS duties.
Pesticide Application List

Fact Sheets:

Checklists:

Pesticide Application List

Agricultural Establishment Owners and Operators: The use of thisform is optional, but if all the information about an application is entered, you will satisfy the 1992 Federal Worker Protection Standard requirement for information that must be displayed at a central place to inform workers and handlers about specific pesticide applications. See this earlier section of the EPA manual "The Worker Protection Standardfor Agricultural Pesticides: How To Comply.
_________________________________________________________________________
                              Application #1              Application #2
_________________________________________________________________________
Area Treated:
Location & Description


_________________________________________________________________________
Product Name


_________________________________________________________________________
EPA Registration
Number


_________________________________________________________________________
Active Ingredient:
Common or
Chemical Name


_________________________________________________________________________
Application:
Month/Day/Time


_________________________________________________________________________
Restricted Entry Interval


_________________________________________________________________________
Do Not Enter Until:
Month/Day/Time


_________________________________________________________________________

Similar data is required by the Federal Recordkeeping Requirements for Certified Applicators of Fedffally Restricted Use Pesticides (RUP). For more information on the RUP recordkeeping requirements, contact AgTicultural Marketing Service, USDA, 8 700 Centerville Rd, Manassas, VA 22110. (703) 330- 7826.


Note to Employers: This 2-page fact sheet will help you comply with the section of the WPS that requires you to provide information to people (other than your own handlers) who clean PPE for you. You are not required to give them this information in written form, but you may find that photocopying (FOR MOSAIC, printing) this fact sheet is an easy way to be sure you pass along all the necessary information.

Information About Cleaning PPE

Protect Yourself From Pesticides

Recommended Methods for Cleaning PPE

Cleaning Eyewear and Respirators

Hand-wash reusable respirator facepieces, goggles, face shields, and shielded safety glasses, following manufacturer's instructions. In general, use mild detergent and warm water to wash the items thoroughly. Rinse well. Wipe dry, or hang in a clean area to air dry.

Cleaning Other PPE

Note to Employers: This fact sheet will help you comply with the section of the WPS that requires you to provide information to people (other than your own handlers) who clean or maintain your pesticide equipment. You are not required to give them this information in written form, but you may find that photocopying (in Mosaic, printing) this fact sheet is an easy way to be sure you pass along all the necessary information.

Working Safely With Pesticide Equipment

Agricultural Establishment Owners & Operators

Agricultural Establishment Owners and Operators: The use of this form is optional, but, if you hire custom applicators or independent crop advisors, you must provide this information to the employers of those persons. This information is necessary to assure that custom applicators and independent crop advisors are protected according to the 1992 Federal Worker Protection Standard. See earlier section of the EPA manual "The Worker Protection Standard for Agricultural Pesticides: How To Comply."

Information To Be Provided to Employers of Custom Applicators and Independent Crop Advisors

Th following information refers to areas that your employees may need to enter, or come within 1/4 mile of on foot, while working, on this agricultural establishment.

__________________________________________________________________________
                              Application #1             Application #2
__________________________________________________________________________
Areas to be Treated or
Under Restricted
Entry Intervals:
Location & Description


__________________________________________________________________________
Entry Restricted Until:
Month/Day/ Time


__________________________________________________________________________
PPE Required for Handlers*



__________________________________________________________________________
Early Entry PPE Required
for Workers*


__________________________________________________________________________
* The only early entry allowed is that which is permitted by the 1992 Federal Worker Protection

Custom Applicators

Custom (for Hire) Applicators: The use of this form is optional, but you must provide this information to the agricultural owners and operators who hire you to apply pesticides. This information is necessary to assure that the grower's employees are protected according to the 1992 Federal Worker Protection Standard. See earlier section of the EPA manual "The Worker Protection Standard for Agricultural Pesticides: How To Comply."

Information to be Provided to Agricultural Establishment Owners and Operators

_________________________________________________________________________
                              Application #1             Application #2
_________________________________________________________________________
Area to be Treated:
Location & Description
_________________________________________________________________________
Product Name
_________________________________________________________________________
EPA Registration Number
_________________________________________________________________________
Active Ingredient:
Common or Chemical Name
_________________________________________________________________________
Application:
Month/Day/Time*
_________________________________________________________________________
Entry Restricted Until:
Month/Day/Time
_________________________________________________________________________
Are Both Treated Area Posting
and Oral Notification Required?
_________________________________________________________________________
PPE Required for Handlers**
_________________________________________________________________________
Early Entry PPE Required for
Workers**
_________________________________________________________________________
Other Label Requirements to
Protect Workers & Others
_________________________________________________________________________
*If the pesticide is not applied as scheduled, the customer must be notified of the corrected time and date before the application, or as soon as possible after the application.
** The only early entry allowed is that permitted by the l992 Federal Worker Protection Standard.

Checklist: WPS Requirements for Agricultural Workers

Have you given your agricultural workers all the protections required by the EPA Worker Protection Standard? Use this list as a reminder. Remember that you have duties to persons other than your worker employees. For complete explanations, refer to "The Worker Protection Standard for Agricultural Pesticides-How To Comply."
Information at a central location (WPS safety poster, application list, location of emergency medical facility)

Pesticide safety training for workers

Decontamination sites (water, soap, towels, etc.)

Emergency assistance (transportation and information)

Restrictions during applications (do not allow workers in area)

Special application restrictions in nurseries

Special application restrictions in greenhouses

Restrictions during restricted-entry intervals (and limitations on early entry)

Notice about applications (oral warnings and treated area posting)

Checklist: WPS Requirements for Pesticide Handlers

Have you given your pesticide handlers all the protections required by the EPA Worker Protection Standard? Use this list as a reminder. Remember that you have duties to persons other than your handler employees. For complete explanations, refer to "The Worker Protection Standard for Agricultural Pesticides-How To Comply."
Information at a central location (WPS safety poster, application list, location of emergency medical facility)

Pesticide safety training for handlers

Decontamination site (water, soap, towels, change of clothing, etc.)

Emergency assistance (transportation and information)

Restrictions during applications (do not allow pesticide to contact anyone directly or through drift)

Monitoring handlers (if handling skull and crossbones pesticides anywhere or fumigants in greenhouses)

Specific instructions for handlers (pesticide label information and how to use application equipment)

Equipment safety (inspection and maintenance of application equipment)

Personal protective equipment (provide, clean, maintain PPE, and prevent heat illness)

Exceptions to personal protective equipment (closed systems, enclosed cabs, and open and enclosed cockpits

Checklist: WPS Requirements for Commercial Handlers

Have you given the handler employees of your commercial pesticide handling establishment all the protections required by the EPA Worker Protection Standard? Use this list as a reminder. Remember that you have duties to persons other than your handler employees. For complete explanations, refer to "The Worker Protection Standard for Agricultural Pesticides-How To Comply."
Pesticide safety training for handlers

Decontamination site (water, soap, towels, change of clothing, etc.)

Emergency assistance (transportation and information)

Restrictions during applications (do not allow pesticide to contact anyone directly or through drift)

Monitoring handlers (if handling skull and crossbones pesticides anywhere or fumigants in greenhouses)

Specific instructions for handlers (pesticide label information and how to use application equipment)

Equipment safety (inspection and maintenance of application equipment)

Personal protective equipment (provide, clean, maintain PPE, and prevent heat illness)

Exceptions to personal protective equipment (closed systems, enclosed cabs, and open and enclosed cockpits)

Checklist: WPS Exemptions for Agricultural Owners Although agricultural owners are encouraged to give all 'I WPS protections to themselves and their families*, the WPS does not REQUIRE them to provide themselves or members of their immediate family with the following:
Information at a central location (WP sa@ety poster, application list, and location of emergency medical facility)

Pesticide safety training for workers or handlers

Decontamination sites (water, soap, towels, change of clothing, etc.)

Emergency assistance (transportation andinformation)

Notice about applications (oral warnings and treated area posting)

Monitoring handlers (if handling skull and crossbones pesticides anywhere or fumigants in greenhouses)

Specific handling instructions (pesticide label information and how to use application equipment)

Equipment safety (inspection and maintenance of application equipment)

All the specific duties related to the care of PPE and management of its use (provide, clean, maintain PPE and prevent heat illness)

The following duties related to early entry:


*Remember that you must provide all protections required by the WPS to persons who are NOT members of your immediate family.
Forward to Appendix C (also Unit 1)
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