"Worker Protection Standard Self Evaluation Checklist Form" - Arizona

Worker Protection Standard Self Evaluation Checklist Form is a legal document that was released by the Arizona Department of Agriculture - a government authority operating within Arizona.

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Download "Worker Protection Standard Self Evaluation Checklist Form" - Arizona

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WORKER PROTECTION STANDARD
SELF EVALUATION
The following form may be used to self-evaluate your particular agricultural establishment to determine
whether your establishment is in compliance with the Environmental Protection Agency’s (EPA), Worker
Protection Standard (WPS).
If you answer NO or UNSURE to any portion of the Self Evaluation, your establishment may not be in
compliance with the WPS or the Arizona Department of Agriculture’s Worker Safety requirements. The
Agricultural Consultation and Training (ACT) Program provides compliance assistance in a non-regulatory,
non-enforcement mode at no charge to you. ACT will be happy to assist you in complying with these
requirements by answering your questions either by telephone or conducting an intensive On-Site Visit at your
establishment and then providing a written report recommending the needed corrections. For more information
or for a consultation, please contact one of the following individuals listed below.
Contacts:
Jennifer Weber
Stacie Archuleta
Field Consultant
Administrative Assistant
1688 W. Adams
1688 W. Adams
Phoenix, AZ 85007
Phoenix, AZ 85007
Phone: (602) 542-0985
Phone: (602) 542-0137
Fax: (602) 364-0830
Fax: (602) 364-0830
jweber@azda.gov
sarchuleta@azda.gov
When completing this Self Evaluation, if you are unsure of a meaning associated with a particular word, at the
end of this form there is a list of definitions as they relate to the WPS and ADA’s Worker Safety requirements.
1
WORKER PROTECTION STANDARD
SELF EVALUATION
The following form may be used to self-evaluate your particular agricultural establishment to determine
whether your establishment is in compliance with the Environmental Protection Agency’s (EPA), Worker
Protection Standard (WPS).
If you answer NO or UNSURE to any portion of the Self Evaluation, your establishment may not be in
compliance with the WPS or the Arizona Department of Agriculture’s Worker Safety requirements. The
Agricultural Consultation and Training (ACT) Program provides compliance assistance in a non-regulatory,
non-enforcement mode at no charge to you. ACT will be happy to assist you in complying with these
requirements by answering your questions either by telephone or conducting an intensive On-Site Visit at your
establishment and then providing a written report recommending the needed corrections. For more information
or for a consultation, please contact one of the following individuals listed below.
Contacts:
Jennifer Weber
Stacie Archuleta
Field Consultant
Administrative Assistant
1688 W. Adams
1688 W. Adams
Phoenix, AZ 85007
Phoenix, AZ 85007
Phone: (602) 542-0985
Phone: (602) 542-0137
Fax: (602) 364-0830
Fax: (602) 364-0830
jweber@azda.gov
sarchuleta@azda.gov
When completing this Self Evaluation, if you are unsure of a meaning associated with a particular word, at the
end of this form there is a list of definitions as they relate to the WPS and ADA’s Worker Safety requirements.
1
2
WORKER PROTECTION STANDARD SELF EVALUATION
Please answer the following questions with either “Yes”, “No”, or “Unsure.”
INFORMATION AT A CENTRAL LOCATION
YES
NO
UNSURE
Pesticide Application List?
Does the Application List include the following:
Product name?
EPA Registration number?
Active ingredient(s) of the product?
Time and date of scheduled application?
Restricted-entry interval (REI) for the product?
Location and description of the treated area?
Does the location and description of the treated area allow
workers/handlers to distinguish the treated area from other
non-treated areas on the establishment?
EPA Pesticide Safety Poster?
If not an EPA pesticide safety poster, does the safety poster include all
of the required information?
Emergency medical information?
Does the emergency information include the name, telephone number
and address of the nearest medical facility?
Is the posted information:
Legible?
Accessible?
Current?
Are workers informed of the Central Location, which should contain the
safety poster or required information, emergency information and notice
of pesticide applications made within the last 30 days, including any
restricted entry interval?
3
WORKER PROTECTION STANDARD SELF EVALUATION (cont’d)
Please answer the following questions with either “Yes”, “No”, or “Unsure.”
PESTICIDE SAFETY TRAINING FOR HANDLERS
YES
NO UNSURE
Is the pesticide handler an employee of:
The agricultural establishment?
A commercial handling establishment?
Has/is the handler:
Been trained within the last three years as a WPS handler?
(or)
Currently a certified applicator of restricted-use pesticides?
(or)
Completed an approved pesticide train-the-trainer program?
Does the handler have:
A current certified applicator certification card?
(or)
A current WPS handler card?
(or)
A trainer agreement?
If the handler does not possess any of the above described cards or trainer
agreement, who provides the training?
A certified applicator?
(or)
A trainer of certified applicators?
(or)
A pesticide handler?
Are some of the training materials approved by EPA?
Did the handler receive information about the labeling requirements such as
safe use of the pesticides, personal protective equipment (PPE) requirements
from the agricultural employer, and have access to the pesticide labeling
during the entire handling task?
Has the handler read the label or been informed in a manner in which they may
fully understand all directions on the label?
Has the handler been properly instructed by their employer on how to safely
and correctly use all of the pesticide handling equipment?
4
WORKER PROTECTION STANDARD SELF EVALUATION (cont’d)
Please answer the following questions with either “Yes”, “No”, or “Unsure.”
PESTICIDE SAFETY TRAINING FOR HANDLERS (cont’d)
YES
NO UNSURE
Do all handlers who enter a treated area, for which an REI is in effect or has
expired within the past 30 days, receive basic pesticide safety training?
Does the employer ensure:
The handlers wear all personal protective equipment (PPE) required by
the pesticide label during the application?
The PPE is clean and is in proper working condition?
The PPE is correctly worn by the handler for intended use?
Is all of the PPE, required by the pesticide label for mixing and loading
pesticides, made available when using:
Closed mixing systems?
Enclosed cabs?
Is the appropriate PPE used when applying pesticides by air in:
An open cockpit?
A closed cockpit?
5