Pesticide Compliance Assessment Form
Evaluate and document compliance with pesticide use regulations in agricultural or pest-control operations.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Operation
*
Agricultural
Pest Control
Other
Pesticide Application Method Used
*
Ground Spraying
Aerial Application
Seed Treatment
Fumigation
Other
Are all pesticide applicators certified and trained as required?
*
Yes
No
Not Applicable
Personal Protective Equipment (PPE) Compliance
*
Rows
Always
Sometimes
Never
Gloves
1
2
3
Protective Clothing
4
5
6
Eye Protection
7
8
9
Respirator
10
11
12
Rate the adequacy of pesticide storage facilities.
*
1
2
3
4
5
How often are pesticide application records updated?
*
After every application
Weekly
Monthly
Rarely/Never
Incident Reporting Procedures in Place?
*
Yes, documented and followed
Yes, but not always followed
No procedures in place
Have there been any pesticide-related incidents in the past 12 months?
*
Yes
No
Overall Compliance Status (based on this assessment)
*
Compliant
Partially Compliant
Non-Compliant
Submit Assessment
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