Pesticide Safety Training Form – Fill Out and Use This PDF

FIELDWORKER SAFETY TRAINING RECORD

NAME OF EMPLOYER: ______________________________DATE:_________________

NAME OF TRAINER: _______________________________________________________

Trainer’s qualification: ________________________________________________________

Symptoms of poisoning: Pinpoint pupils, nausea		Location of pesticide safety information series (PSIS)
shortness of breath, dizziness, blurred vision. Ways		Material safety data sheets (MSDS), pesticide use
poisoning or injury can occur.		reports, safety posters, and restricted entry intervals.
Wash hands and arms with soap and water: Before		The need for immediate decontamination of skin and
eating drinking, smoking, or going to the bathroom.		eyes when exposure occurs.
Emergency Eye flushing techniques.
Wash completely at the end of the workday and		Employee’s rights: against discharge, discrimination,
change into clean clothing.		rights to receive information.
Wear clean work clothing daily. Be aware of		Routes through which pesticides enter the body.
pesticides residues on clothing.
Understanding the immediate and long-term hazards		Prevention, recognition, and first aid treatment of heat
involved in handling pesticides. Known or		related illness.
suspected chronic and acute effects.
Emergency medical information: Name, address,		Restricted entry intervals and posting. Do not enter
phone number of clinic, physician, or hospital		treated areas.
emergency room and where information is located.
Never take home pesticide containers used at work.

Print Your Name	Sign Your Name
1. _________________________________	______________________________
2. _________________________________	______________________________
3. _________________________________	______________________________
4. _________________________________	______________________________
5. _________________________________	______________________________
6. _________________________________	______________________________
7. _________________________________	______________________________
8. _________________________________	_______________________________
	This form available in Spanish

ARCHIVO DE ENTRENAMIENTO DE PESTICIDAS

PARA CAMPESIONS

NOMBRE DE PATRON: ______________________________FECHA: ___________________

NOMBRE DE ENTREADOR: ____________________________________________________

CALIFICACIONES DE LENTRENADOR: ___________________________________________

Síntomas de envenenamiento: Pupilas muy pequeñas,		Localización de Serie de Información de Seguridad con
nauseas, vértigo, dolor de cabeza, visión borrosa,		Pesticidas (PSIS) o hojas de seguridad de producto (MSDS) ,
respiración breve. Modo en envenenamiento o lesión		archivos de aplicaciones de pesticidas, letreros de seguridad, y
puede ocurrir.		intervalos restringidos de reingreso (REI).
Lave las manos y brazos con agua y jabón: Antes de		La necesidad para decontaminación inmediatamente de la piel
comer, beber, fumar y ir al baño. Técnicas de emergencia		y los ojos cuando sucede exposición.
para enjuagarse los ojos.
Lavarse completamente al fin del día de trabajo:		Derechos del empleado: contra descarga, discriminación y
		derechos de recibir información.
Cambiarse a ropa limpia.
Use ropa de trabajo limpia diariamente. Darse cuenta de		Rutas a través como pesticidas pueden entrar al cuerpo: boca,
residuos de pesticidas en su ropa.		piel, ojos, inhalación.
Entendimiento de los peligros del uso de pesticidas		Prevención, reconocimiento, primeros auxilios y tratamiento de
inmediatos y de largo plazo; los efectos sospechosos o		enfermedad relacionada al calor.
conocidos agudos o crónicos.
Donde buscar atención medica en emergencia: Nombre,		Intervalos de entrada restringidos (REI) y letreros de REI. No
domicilio, numero de teléfono de la clínica, doctor, o		entre a una área tratada.
cuarto de emergencia del hospital.
Nunca se lleve envases de pesticidas usadas en su trabajo
para su casa.
Escriba su Nombre en Letra de Molde		Firma
1. _________________________________	______________________________
2. _________________________________	______________________________
3. _________________________________	______________________________
4. _________________________________	______________________________
5. _________________________________	______________________________
6. _________________________________	______________________________
7. _________________________________	______________________________
8. _________________________________	_______________________________
9. _________________________________	_______________________________

Medical Supervision Program

MEDICAL SUPERVISION WRITTEN AGREEMENT

I, ___________________________(Physician name), agree to provide medical supervision for

the employees of __________________________________________.

(Grower or Company)

I possess a copy of, and am aware of the contents of, the following documents:

Medical Supervision of Pesticide Workers - Guidelines for Physicians.

____________________________________________

(Physician)

____________________________________________

(Address)

____________________________________________

(City, State, Zip)

____________________________________________

(Telephone)

____________________________________________

(Signed)

___________________________________________

(Grower Name/Company)

___________________________________________

(Address)

___________________________________________

(City, State, Zip)

__________________________________________

(Telephone)

__________________________________________

(Signed)

WRITTEN TRAINING PROGRAM

Employer Name: _________________________________________________

Trainer’s Name: _________________________________________________

Trainer’s Qualification: _________ PA: _________ QAL/QAC: _________ PCA: _________

Training Materials:

Name of videos, pamphlets, or other training materials, and a brief description:

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

4.______________________________________________________________________

Pesticide labeling from the following products:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Pesticide Safety Information Series (PSIS) leaflets used:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Materials Safety Data Sheets (MSDS) for the following products:

________________________________________________________________________

________________________________________________________________________

_________________________________________________________________________

LETTER OF AUTHORIZATION

To: _______________________________________, County Agricultural Commissioner

From: ________________________________________________________________________

OPERATOR OF THE PROPERTY (PRINT NAME)

_____________________________________________________________________________

ADDRESS

_____________________________________________________________________________

CITY, STATE, ZIP, PHONE

The authorized representative named below may represent me in obtaining a restricted material permit or operator identification number for use in ___________________County. I understand

that this authorization does not relieve me of liability for violations of pesticide laws or regulations on my property. This authorization shall remain in effect until I revoke it in writing to the Agricultural Commissioner.

Signature: __________________________________________ Date: _____________________

(OPERATOR OF THE PROPERTY)

Title: ________________________________________________________________________

Authorized Representative: _______________________________________________________

(PRINT NAME)

I am the property operator’s: [ ] employee; [ ] relative; [ ] employee PCA;

[ ] other, SPECIFY_______________________

I hereby certify that the information above is correct to the best of my knowledge. I also understand that, in the event of violation of pesticide laws or regulations, I could be held liable either separately or together with the property operator.

Signed: _______________________________________________ Phone: _________________

AUTHORIZED REPRESENTATIVE

3CCR 6420(a): “Permits for agricultural use of a restricted material shall be issued in the name of the operator of the property to be treated. The permittee or, when allowed by the commissioner, the permittee’s authorized representative or licensed pest control adviser shall sign the permit. The authorized representative or licensed pest control adviser shall provide the commissioner with written documentation from the permittee to act on his/her behalf.”

3CCR 6000: “Operator of the property” means a person who owns the property and/or is legally entitled to possess or use the property through terms of a lease, rental contract, trust, or other management arrangement.

Application-Specific Information Display Chart

			Restricted
Pesticide	Location	Date/Time	Entry	Active ingredient	Registration
			Interval		Number
			(REI)

Complete chart within 24 hours of the application and display where employees can review the information with unimpeded access.

Application-Specific Information Display Chart (Abbreviated)

Product active ingredients and EPA Registration numbers are found on the labels displayed with this chart.

Pesticide	Location	Date/Time	Restricted
			Entry Interval

Complete chart within 24 hours of the application and display with the pesticide labels used where employees can review the information with unimpeded access.