Handler (including certified applicator) Information and PPE Tasks Handlers are Trained Respirator Information Handler Name, Address, and Phone Employer Name, Address, and and Authorized to Perform* PPE (check all that apply) (leave blank if respirator” is checked “no Number Phone Number (check number(s) from under PPE) below) 1 Long-sleeved shirt/long-pants, shoes, socks Make: 2 Chemical-resistant apron Model: 3 Chemical-resistant footwear and socks Type: 4 Protective eyewear (NOT goggles) Style: 5 Chemical-resistant gloves Size: 6 Air-purifying respirator Cartridge/canister type: 7 Self contained breathing apparatus Fit test date: 8 Other: Training date: 9 No respirator Medical qualification date: 10 Make: 11 PPE training date: Type: Style: Size: Cartridge/canister type: Fit test date: Training date: Medical qualification date: Make: Model: Type: Style: Size: Cartridge/canister type: Fit test date: Training date: Medical qualification date: The above handler has received Fumigant Safe Handling Information within the past 12 months. *1. Loaders, drivers, tractor co-pilots, shovelers, cross-ditchers, or other direct application participants 6. Monitoring fumigant air concentrations 2. Cleaning up fumigant spills (does not include emergency personnel not associated with the application) 7. Handling or disposing of fumigant containers 3. Tasks with liquid contact potential 8. Cleaning, handling, adjusting, or repairing equipment that may contain fumigant residues 4. Installing, perforating or removing 9. Installing, repairing, operating, or removing irrigation equipment in the application block or 5. Repairing, or monitoring tarps until14 days after the application is complete if tarps are not perforated and removed buffer zone during those 14 days. 10. Performing scouting, crop advising, or monitoring tasks in the application block or buffer zone 11. Performing other WPS handling tasks Comments/notes:
Handler (including certified applicator) Information and PPE Handler Name, Address, and Phone Number Employer Name, Address, and Phone Number Tasks Handlers are Trained and Authorized to Perform* (check number(s) from below) PPE (check all that apply) Respirator Information (leave blank if “no respirator” is checked under PPE) 1 2 3 4 5 6 7 8 9 10 11 Long-sleeved shirt/long-pants, shoes, socks Chemical-resistant apron Chemical-resistant footwear and socks Protective eyewear (NOT goggles) Chemical-resistant gloves Air-purifying respirator Self contained breathing apparatus Other: No respirator PPE training date: Make: Model: Type: Style: Size: Cartridge/canister type: Fit test date: Training date: Medical qualification date: Make: Type: Style: Size: Cartridge/canister type: Fit test date: Training date: Medical qualification date: Make: Model: Type: Style: Size: Cartridge/canister type: Fit test date: Training date: Medical qualification date: The above handler has received Fumigant Safe Handling Information within the past 12 months. *1. Loaders, drivers, tractor co-pilots, shovelers, cross-ditchers, or other direct application participants 2. Cleaning up fumigant spills (does not include emergency personnel not associated with the application) 3. Tasks with liquid contact potential 4. Installing, perforating or removing 5. Repairing, or monitoring tarps until14 days after the application is complete if tarps are not perforated and removed during those 14 days. 6. Monitoring fumigant air concentrations 7. Handling or disposing of fumigant containers 8. Cleaning, handling, adjusting, or repairing equipment that may contain fumigant residues 9. Installing, repairing, operating, or removing irrigation equipment in the application block or buffer zone 10. Performing scouting, crop advising, or monitoring tasks in the application block or buffer zone 11. Performing other WPS handling tasks Comments/notes:
chloro-handler-info-template-9-11-12.docx