Form DPR-HSA-118 "Pesticide Use Reporting for School and Child Day Care Center Employees" - California

What Is Form DPR-HSA-118?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2016;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DPR-HSA-118 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-HSA-118 "Pesticide Use Reporting for School and Child Day Care Center Employees" - California

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PESTICIDE USE REPORTING FOR SCHOOL
AND CHILD DAY CARE CENTER EMPLOYEES
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-HSA-118 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 1 of 2
APPLICATION YEAR SCHOOL DESIGNEE (IPM COORDINATOR)
DISTRICT / CENTER NAME
LICENSE / CERTIFICATE NUMBER (OPTIONAL)
REPORT PREPARED BY:
E-MAIL ADDRESS
CITY
PHONE NUMBER
Pest
Amount of Pesticide
Control
School CDS #/Child Day Care Facility #
County
Date & Time
Location
Manufacturer & Name of
EPA REG. Number on Label or
Product Used
Code
OR Name & Address AND Specify if
Code
Application
Product Applied
CA Reg. Number for adjuvants
(# from list on back)
School or Child Day Care Facility
Completed
(check for write in
(from list
(include alpha code, if listed)
unit from label)
on back)
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
Use this form ONLY to report pesticide applications made by schoolsite employees, staff, and volunteers at schools and child care centers.
DO NOT report pesticide use by pest management professionals contracted to apply pesticides at schoolsites. They will report their own
use. Report must be submitted no later than January 30th of the year following the year of use to:
School Pesticide Use Reporting, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, CA 95812-4015
PESTICIDE USE REPORTING FOR SCHOOL
AND CHILD DAY CARE CENTER EMPLOYEES
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-HSA-118 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 1 of 2
APPLICATION YEAR SCHOOL DESIGNEE (IPM COORDINATOR)
DISTRICT / CENTER NAME
LICENSE / CERTIFICATE NUMBER (OPTIONAL)
REPORT PREPARED BY:
E-MAIL ADDRESS
CITY
PHONE NUMBER
Pest
Amount of Pesticide
Control
School CDS #/Child Day Care Facility #
County
Date & Time
Location
Manufacturer & Name of
EPA REG. Number on Label or
Product Used
Code
OR Name & Address AND Specify if
Code
Application
Product Applied
CA Reg. Number for adjuvants
(# from list on back)
School or Child Day Care Facility
Completed
(check for write in
(from list
(include alpha code, if listed)
unit from label)
on back)
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
School
(vol.)
OZ
ML
PT
(wt.)
Day Care
GR
OZ
LB
Use this form ONLY to report pesticide applications made by schoolsite employees, staff, and volunteers at schools and child care centers.
DO NOT report pesticide use by pest management professionals contracted to apply pesticides at schoolsites. They will report their own
use. Report must be submitted no later than January 30th of the year following the year of use to:
School Pesticide Use Reporting, Department of Pesticide Regulation, P.O. Box 4015, Sacramento, CA 95812-4015
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
DPR-HSA-118 (REV. 12/16)
PEST MANAGEMENT & LICENSING BRANCH
Page 2 of 2
INSTRUCTIONS:
1. Each line is an individual pesticide application. Report only one schoolsite, date/time, and pesticide per line. Multiple pages will be needed
if you need to report more than 5 pesticide applications.
2. A name and address is required for each schoolsite. A cover sheet with all schoolsite names/addresses can be included with your report
to prevent repetitive writing/typing.
3. Applicators: If you are mixing a concentrate with a liquid, report the amount of concentrate applied. For products that don’t require dilution,
report the amount of finished product applied.
PEST CONTROL CODES:
Code 10 - Structural Pest Control .......................... includes pest control work performed within or on buildings or other structures
Code 30 - Landscape Maintenance Pest Control... includes pest control work performed on landscape plantings around buildings
Code 80 - Vertebrate Pest Control ......................... includes pest control work performed by public agencies or work under the supervision of the State or county agricultural commissioner
LOCATION CODES:
1
Administration Bldg
5
Cafeteria/Kitchen
9
Landscape (indoor)
13
Multipurpose Room
17
Vehicle
2
Athletic Field
6
Classroom
10
Landscape (outdoor)
14
Playground
18
Multiple Locations
3
Auditorium
7
Gymnasium
11
Library
15
Pool
19
Other (Please indicate)
4
Bldg, Exterior
8
Hardscape (parking lot, sidewalk, etc.)
12
Locker Room
16
Restroom
____________________
Reason for application is not required for reporting. This form, when filled out completely, can be used as the pesticide use record required under HSA.
Reasons for application (required for Healthy Schools Act recordkeeping).
Application 1:
Application 2:
Application 3:
Application 4:
Application 5:
Page of 2