2019 required record checklist - gap connections flue_gapc... · 2019-01-03 · 2 2019 required...

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2019 Required Record Checklist 2019 Operation Records

� Contact Information � Primary and Associated Grower Information � 2019 Tobacco Type and Acres � Farm Infrastructure � Curing Information

Nutrient Management

� Field/Tract ID Records o Field/Tract ID o Farm Name or Location o County o FSA Number o Tobacco Acres o Latest Soil Testing Date o Date of Last Lime Application o Rate of Lime (tons/acre)

� Greenhouse Fertilization Records o Greenhouse ID Number o Transplant Batch Number o Date o Types of Fertilizer o Rate (per 1,000 gallons)

� Field/Tract Fertilization Records o Field/Tract ID o Date o Application Timing o Analysis (N-P-K) o Rate of Application (lbs./acre) o K20 from Muriate, if applied after

December 31 (lbs./acre) o Muriate of Potash Date of Application

� Animal Manure or Litter Application Records o Date(s) Animal Manure Tested for

Nutrient Content o Field/Tract ID o Date o Type of Manure o Rate

� Soil Test Results � Nutrient Management Plan (If Applicable)

IPM and CPA

� Scouting Records o Field Scouting Dates o Field/Tract ID o Pest Identified during Scouting o Level of Infestation of Pest Identified o Corrective Actions Taken (Include Date

of Action)

o Follow-up on Pest Control to Determine the Effectiveness of Actions Taken

� CPA Applicator License Information o Applicator Name o License Number

� CPA Information Records o Brand Name o EPA Registration Number o Active Ingredient o REI (Hours) o Label on File o SDS on File

� Greenhouse CPA Records o Greenhouse ID Number o Transplant Batch Number o Date o Applicator o Brand/Product Name or Reference

Number o Reason for Application o Rate per 1,000 square feet o Total Application o Start/Finish Time

� Field/Tract CPA & Sucker Control Records o Field/Tract ID o Date o Applicator o Reason for Application o Brand/Product Name or Reference

Number o Rate per Acre o Total Application o Size of Area Treated o Start/Finish Time o Method of Application

� Sprayer Calibration Records o Date Calibrated o Sprayer Brand and Model o Sprayer Type o Nozzle Type and Size o Pressure o Speed (mph) o Throttle (rpm) o Tractor Model o Tractor Gear o Spray Volume (gallons per acre)

� Pesticide License

Crop and Operations

� Seed Selection Records o Variety Selection o Greenhouse ID Number

2019 Required Record Checklist


2019 Required Record Checklist o Transplant Batch Number o Seedling Source o Variety Name o Seed Lot Number o LC Variety (Burley & Dark Only) o Date of Seeding

� Transplanting and Topping Records o Plant Population o Row Spacing o Plant Spacing in Row o Field/Tract ID o Transplanting Date o Transplant Batch Number o Date of Topping o Topping Height (approximate number of

leaves left) � Weed Prevention Program

o Herbicides used o Number of cultivations o Control of weeds in field borders o Preharvest scouting and cleanup

practices � FSA 578

Curing and Barn Management – Flue

� Flue Curing Facility Records o Barn Testing Report o Barn ID Number o Barn Make and Model o Heat Exchanger Brand o Initial Reading o Final Reading o Barn Status Pass/Fail

� Flue Harvesting and Curing Records o Field/Tract ID o Harvest Date o Method of Harvesting o Stalk Position o Barn ID o Fuel Source o Bale ID Number(s)

Curing and Barn Management – Air & Fire

� Air Curing Facility Records o Farm Name o Barn/Structure ID o Type

§ Outdoor Structure § Multi-tier § Number of tiers

o Barn Size

o Spacing of Sticks o Number of Stalks per Stick

� Air Harvesting and Curing Records o Harvest Date o Field/Tract ID o Barn/Structure ID o Date Housed o Date Removed from Housing o Spacing of Sticks o Tobacco Ordering Method o Bale, Box or Hogshead ID Number(s)

� Fire Curing Facility Records o Farm Name o Barn/Structure ID o Type

§ Outdoor Structure § Multi-tier § Number of tiers

o Barn Size o Spacing of Sticks o Number of Stalks per Stick

� Fire Harvesting and Curing Records o Harvest Date o Field/Tract ID o Barn/Structure ID o Date Housed o Date Removed from Housing o Spacing of Sticks o Tobacco Ordering Method o Bale, Box, or Hogshead ID Number(s)

� Firing Records o Barn/Structure ID o Date Fire Started o Date Fire Ended o Fuel Source o Maximum Temperature

� Barn Inspection Information – English & Spanish � Barn Inspection Log

o Barn ID o Date o Who did the Inspection o Comments

Non-Tobacco Related Materials

� NTRM Inspection Information – English & Spanish

� NTRM Inspection Log o Date o Who did the Inspection o Areas Inspected o Comments



2019 Required Record Checklist Agrochemical Storage and Soil & Water

� CPA Inventory Records o Reference Number o Brand Name/Product/Common Name o Storage Area o Amount

� Rainfall Records o Field/Tract ID o Date o Amount of Precipitation o Crop Condition

� Irrigation Records o Field/Tract ID o Date o Source of Irrigation Water o Application Type o Amount Applied o Crop Condition before Irrigating

� Crop Rotation Records o Field/Tract ID o Field HEL (Yes or No) o 2016

§ Crop § Tillage Type § Cover Crop

o 2017 § Crop § Tillage Type § Cover Crop



� Safety Data Sheets (SDS Sheets) � Agrochemical Labels � Conservation Plan (If Field/Tract ID considered

HEL)

Recruiting and Hiring Workers

� Labor Numbers Records � Worker Recruiting & Hiring Records

o Name o Date of Birth o Type of Labor o Work State Date o Work End Date o Date I-9 Completed

o Collected Emergency Contact Information

o Provided Terms & Conditions of Employment

o Discussed Anti-Discrimination Policy o Discussed Farm Emergency Plan

� Terms and Conditions of Employment US DOL Form WH-516

� Worker Termination Record o Employee Name o Reason for Termination o Documentation

� Non-Immediate Family Minors Working Record o Full Name o Date of Birth o Parental Consent o Residence o Permanent Address

� I-9 Forms � Parental Consent (if non-immediate family

minors, ie. under 18 on the farm) � Wage Statements � If using a Farm Labor Contractor (FLC)

o I-9 Forms o FLC Certificate of Registration from

DOL o Housing Inspection (If authorized to

house) o Copy of Vehicle Insurance (If authorized

to transport) o Driver’s License (If authorized to

transport) o Doctor’s Certificate (If authorized to

transport) o Employment Terms & Conditions for

FLC Workers o Wage Statements for FLC Workers

Worker’s Rights & Responsibilities & Worker Concern Helpline

� Worker Concern Process Documentation o Grower ID# o Grower Name o Farm Name o Trainer(s) o Date o Printed Name of worker o Signature of worker

� Anti-Discrimination Policy



2019 Required Record Checklist Housing, Sanitation, & Transportation

� Housing Terms & Conditions DOL WH-521 � Vehicle Information Records

o Vehicle o Make/Model o Year o Annual Checklist

§ Valid Tags § Insurance § State Inspection (If required) § Federal Inspection (If required)

� Driving Information Records o Driver’s Name o Driver’s License Number o Driver License Expiration Date o Date on Doctor Certificate o IF FLC or FLCE

§ Certificate § Authorized to Transport § Authorized to Drive

� Vehicle Inspection Log o Vehicle o Date

� Housing Inspection Certificate

Worker Training and Farm Safety

� OSHA Forms 300, 300A, & 301 � How to Prepare for an Emergency or Disaster

(English & Spanish) � Emergency Response Plan

o Farm Name o Address o Telephone o Contact Name o Last Revision Date o Employee Evacuation System o Person responsible for Farm Roster at

Evacuation Site o Evacuation Site Location

� Farm Roster o Name o Phone o Special Assistance Needed

� List of Important Numbers � In Case of Medical Emergency

o Name of Person Trained in CPR, First Aid or AED

o Contact number o Location of First Aid Kits o Location of Automate External

Defibrillators (AED)

� In Case of Fire Emergency � In Case of Severe Weather/Tornado Sheltering

o Severe weather/Tornado Shelter Locations

o Assigned Person to monitor severe weather

o Assigned Person to direct people to shelter

� Worker Safety Training Records o Farm Name o Source of Training

§ Verbal Discussion § Training Video § Tailgate Training Kits § Farm Safety & Compliance

Event o Trainer name o Date o Training Topics o Printed Name of worker o Signature of worker

� Worker Crop Integrity Training Records o Farm Name o Source of Training

§ Verbal Discussion § Training Video § Tailgate Training Kits § Farm Safety & Compliance

Event o Trainer name o Date o Training Topics o Printed Name of worker o Signature of worker


Operation Records

Contact Information

Farm Address:

City: State: Zip:

County:

Phone:

Email Address:

Primary Grower Name:

Grower ID: Grower Date of Birth: / /

Associated Grower Name:








2019 Operation Records 2019 Operation Records

Farm Infrastructure Type Total Number

Flue-cured Curing Barns

Dark-firedCuringBarns

Air-cured Curing Barns

Outdoor Air-cured Curing Structures*

Storage Facilities

Shipping Facilities (Air and Fire Only) Sand Reels/Tumblers (Flue Only) Leaf Loaders (Flue Only)

Mechanical Tobacco Harvesters

2019 Total Tobacco Acres: _____________________

Tobacco Type Total Acres Tobacco Type Total Acres

Flue-cured Maryland

Organic Flue-cured Wisconsin

Burley Cigar

Organic Burley Louisiana Perique

Dark Air Other: ______________

Dark Fired Other: ______________

2019 Operation Records

Box Barns

Rack Barns

Open

Enclosed

Curing Information for Flue-Cured Tobacco

Type of Curing Fuel Used:

Pounds of Tobacco Cured per Gallon of Fuel:

Curing Information for Dark-Fired Tobacco

Type of Wood Source for Curing Fuel:

* For outdoor curing structures, give total stick capacity for Total Number

Nutrie

nt

Ma

na

ge

me

nt

TAB 1

Included Records:• Field/Tract ID Records

• Greenhouse Fertilization Records

• Field/Tract ID Fertilization Records

• Animal Manure or Litter Application Records

Copies of the following will be required:• Soil Test Results• Nutrient Management Plan (if applicable)

Nutrient Management

Fiel

d/Tr

act I

D R

ecor

ds

1 | Nutrient Management

Fie

ld/T

ract

ID

Farm

Nam

e or

C

ount

y FS

A N

umbe

r To

bacc

o La

test

Soi

l D

ate

of L

ast

Rat

e of

Lim

e

Lo

catio

n

A

cres

Te

stin

g D

ate

Lim

e A

pplic

atio

n (to

ns/a

cre)

Gre

enho

use

Fert

iliza

tion

Rec

ords


G

reen

hous

e ID

Tr

ansp

lant

D

ate

Type

s of

Fer

tiliz

er

Rat

e

Num

ber

Bat

ch N

umbe

r

(p

er 1

,000

/gal

lons

)

Fiel

d/Tr

act F

ertil

izat

ion

Rec

ords


R

ate

of F

ield

/Tra

ct ID

*

Dat

e A

pplic

atio

n Ti

min

g A

naly

sis

(N-P

-K)

App

licat

ion

K20

from

Mur

iate

, if a

pplie

d M

uria

te o

f Pot

ash

(lb

s./a

cre)

af

ter D

ecem

ber 3

1 (lb

s./a

cre)

D

ate

of A

pplic

atio

n

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

Pre

-pla

nt

Tran

spla

ntin

g

Sid

e-dr

essi

ng

Folia

r App

licat

ion

*Fie

ld/T

ract

ID fr

om T

ab 1

Nut

rient

Man

agem

ent R

ecor

ds P

age

1

Ani

mal

Man

ure

or L

itter

App

licat

ion

Rec

ords


Dat

e(s)

Ani

mal

Man

ure

Test

ed fo

r Nut

rient

Con

tent

: ___

____

____

____

____

____

____

____

__

Fie

ld/T

ract

ID*

Dat

e

Typ

e of

Man

ure

Rat

e

*Fie

ld/T

ract

ID fr

om T

ab 1

Nut

rient

Man

agem

ent R

ecor

ds P

age

1

TAB 2

Included Records:• Scouting Records

• CPA Applicator License Information

• CPA Information Records

• Greenhouse CPA Records

• Field/Tract CPA & Sucker Control Records

• Sprayer Calibration Records

Copies of the following will be required:• Pesticide license

IPM & CPA

IPM

&C

PA

Scou

ting

Rec

ords

1 | IPM and CPA

Follo

w-u

p on

Pes

t

Field

Pe

stIdentifi

ed

Levelof

Con

trolPracticesto

Sc

outin

gField/TractID*

DuringSc

outin

gInfestationof

CorrectiveActionsTaken(IncludeDateofAction)

Determinethe

Dates

PestIdentifi

ed

Effectivenessof

Act

ions

Tak

en

*Fie

ld/T

ract

ID fr

om T

ab 1

Nut

rient

Man

agem

ent R

ecor

ds P

age

1

2 | IPM and CPA

CPA Applicator License Information

List all the applicators and license numbers used on your farm operation below. If pesticideapplicator is not licensed, list the license number of the licensed supervisor.

Reference Number Applicator Name License Number

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

3 | IPM and CPA

CPA Information Records

Reference Brand EPARegistration ActiveIngredient REI Number Name Number (Hours)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

SaveTime:TheFederalrecordkeepingregulationsrequirethecertifiedprivateapplicatortorecordthebrand/product name and the U.S. Environmental Protection Agency (EPA) registration number of the federally restricted-use pesticide (RUP) he/she applies. You will be able to save time by listing the brand/product name, EPA registration number, and active ingredient(s) of the pesticides you apply on this page and then entering the corresponding number(s) to complete your CPA records.

LabelonFile

“ 3 ”

SDSonFile

“ 3 ”

Gre

enho

use

CPA

Rec

ords

4 | IPM and CPA

T

rans

plan

t

B

rand

/ Pr

oduc

t

Gre

enho

use

Bat

ch

D

ate

App

licat

or*

Nam

e or

Ref

eren

ce

Rea

son

for A

pplic

atio

n

R

ate

/ 1,0

00

Tot

al

Star

t /

ID N

umbe

r

N

umbe

r

Num

ber*

*

sq. f

t.***

A

pplic

atio

n

Fin

ish

Tim

e

*App

licat

or o

r ref

eren

ce n

umbe

r fro

m T

ab 2

IPM

and

CPA

Pag

e 2

**C

PA In

form

atio

n R

ecor

ds fr

om T

ab 2

IPM

and

CPA

Pag

e 3

**

*Tot

al A

mou

nt o

f Pro

duct

Use

d pe

r 100

0ft2

(ind

icat

e un

it: o

z., l

b., p

t., q

t., g

al.)

Fiel

d/Tr

act C

PA a

nd S

ucke

r Con

trol

Rec

ords

5 | IPM and CPA

Fie

ld/

B

rand

/ Pr

oduc

t

Si

ze o

f St

art /

Tra

ct

N

ame

or R

efer

ence

R

ate

/ Acr

e To

tal

Are

a Fi

nish

M

etho

d of

ID

* D

ate

App

licat

or**

R

easo

n fo

r App

licat

ion

Num

ber

****

A

pplic

atio

n Tr

eate

d Ti

me

App

licat

ion

*Fie

ld/T

ract

ID fr

om T

ab 1

Nut

rient

Man

agem

ent P

age

1**

App

licat

or o

r ref

eren

ce n

umbe

r fro

m T

ab 2

IPM

and

CPA

Pag

e2**

*CPA

Info

rmat

ion

Rec

ords

from

Tab

2 IP

M a

nd C

PA P

age

3

****

Tota

l Am

ount

of P

rodu

ct U

sed

(indi

cate

uni

t: oz

., lb

., pt

., qt

., ga

l.)

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

Han

dS

pray

erH

and

Spr

ayer

6 | IPM and CPA

Sprayer Calibration Records

The effectiveness of any pesticide depends upon the proper application and placement of the chemical. The purpose of calibration is to ensure that your chemical application machinery is uniformly applying the correct amount of material over a given area. Although you may have the right chemical mixture, it is still possible to apply the wrong amount.

Date Date Date Date Date Calibrated Calibrated Calibrated Calibrated Calibrated

SprayerBrand and Model

SprayerType

Nozzle Typeand Size

Pressure

Speed (mph)

Throttle (rpm)

TractorModel

Tractor Gear

SprayVolume(gal/ac)

TAB 3

Included Records:• Seed Selection Records

• Transplanting and Topping Records

• Weed Prevention Program

Copies of the following will be required:• FSA 578 Forms

• Publications on variety selection

Crop & Operations

Cro

p &

Op

era

tions

1 | Crop and Operations

Seed

Sel

ectio

n R

ecor

ds*R

equi

red

for P

lant

s Pr

oduc

ed a

nd P

urch

ased

Varie

tySelectio

n: P

leas

e lis

t the

reso

urce

s or

sou

rces

of i

nfor

mat

ion

used

to m

ake

varie

ty s

elec

tion

deci

sion

s: _

____

____

____

____

____

____

____

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Bat

ch 1

: V

arie

ty, D

ate

Se

eded

:

Bat

ch 2

: Var

iety

, Dat

e S

eede

d:

Bat

ch 3

: V

arie

ty, D

ate

Se

eded

:

Seed

Sele

cti

on

Re

co

rds

*R

eq

uir

ed

fo

r P

lan

ts P

rod

uced

an

d P

urc

hased

Va

rie

ty S

ele

cti

on

: P

lease

list

th

e r

eso

urc

es o

r so

urc

es

of

info

rmatio

n u

sed

to

make

va

rie

ty s

ele

ctio

n d

eci

sio

ns:

Tra

ns

pla

nt

Ba

tch

No

.: T

he

tra

nsp

lant b

atc

h n

um

be

r is

cre

ate

d b

y yo

u a

nd is

use

d to

ide

ntif

y ea

ch s

epa

rate

ba

tch

of

tra

nsp

lan

ts u

sed

in y

ou

r op

era

tion

. A

se

pa

rate

nu

mbe

r sh

ou

ld b

e g

iven

to

ea

ch b

atc

h o

f tr

an

spla

nts

of th

e s

am

e s

ou

rce

, va

rie

ty, lo

t nu

mbe

r, a

nd s

ee

de

d a

t th

e s

am

e tim

e in

the

sa

me

g

reen

ho

use

. S

ee

dia

gra

m b

elo

w o

f g

ree

nh

ou

se b

ed

. G

reen

hous

e ID

No

.*

Tra

ns

pla

nt

Ba

tch

No

.

See

dlin

g S

ou

rce

V

arie

ty N

am

e

S

ee

d L

ot

#

LC

Var

iety

(B

urle

y &

Dar

k O

NL

Y)

D

ate

of S

eed

ing

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

□ G

row

n □

Pu

rch

ase

d

□ Y

es

□ N

o

*Th

is G

ree

nho

use

ID

nu

mb

er

is c

reate

d b

y yo

u a

nd

is u

sed

to

ide

ntif

y ea

ch s

ep

ara

te g

reen

ho

use

use

d in

you

r o

pe

ratio

n.

Gre

enho

use

Tran

spla

nt

Seed

ing

Varie

ty

Seed

LC

Var

iety

D

ate

of

ID N

o*

Bat

ch N

o.

Sour

ce

Nam

e Lo

t #

(Bur

ley

& D

ark

ON

LY)

Seed

ing

*Thi

s G

reen

hous

e ID

num

ber i

s cr

eate

d by

you

and

is u

sed

to id

entif

y ea

ch s

epar

ate

gree

nhou

se u

sed

in y

our o

pera

tions

.

TransplantBatchNo.:

The

trans

plan

t bat

ch n

umbe

r is

crea

ted

by y

ou a

nd is

use

d to

iden

tify

each

sep

arat

e ba

tch

of tr

ansp

lant

s us

ed in

you

r ope

ratio

n.A

sepa

rate

num

ber s

houl

d be

giv

en to

eac

h ba

tch

of tr

ansp

lant

s of

the

sam

e so

urce

, var

iety

, lot

num

ber,

and

seed

ed a

t the

sam

e tim

e in

the

sam

e gr

eenh

ouse

.S

ee d

iagr

am a

bove

of g

reen

hous

e be

d.

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

Gro

wn

Pur

chas

ed

Yes

No

2 | Crop and Operations

Tran

spla

ntin

g an

d To

ppin

g R

ecor

ds

To

ppin

g H

eigh

t

Fiel

d/Tr

act I

D*

Tran

spla

ntin

g Tr

ansp

lant

D

ate

(app

roxi

mat

e nu

mbe

r of

Date

BatchNum

ber**

ofTop

ping

leavesleft)

* Fi

eld/

Trac

t ID

from

Tab

1 N

utrie

nt M

anag

emen

t Pag

e 1

** T

rans

plan

t Bat

ch N

o. fr

om T

ab 3

Cro

p an

d O

pera

tions

Pag

e 1

Pla

nt P

opul

atio

n (P

lant

s/ac

re):

____

____

____

____

____

R

ow S

paci

ng: _

____

____

____

____

____

_

Pla

nt S

paci

ng in

Row

: ___

____

____

____

____

Prog

ramfo

rPreventingWeedSe

edCon

taminationofHarvestedLeaf(Pa

lmerAmaranth,otherPigweed,Ragweed,Grasses)

Her

bici

des

used

___

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

Num

berofC

ultivations_____________________Controlofw

eedsinfieldborders_____________________

Pre

harv

est s

cout

ing

and

clea

nup

prac

tices

___

____

____

____

____

____

____

____

____

____

____

____

____

__

Oth

er (h

and

hoei

ng, e

tc.)

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

TAB 4

Included Records:• Flue Curing Facility Records

• Flue Harvesting and Curing Records

Curing & Barn Management — Flue

Curin

g

and

Ba

rnM

ana

ge

me

nt

1 | Curing & Barn Mgmt.-Flue

Curing Facility Records - Flue

GAPConnectionsCertification--BarnTestingReport

Farmer or Farm Name: ____________________________ Testing Entity: _____________________ Signature of Barn Tester: ___________________________ Date of Testing: ___________________ Barn Location: __________________________________ CO2 Meter Make: __________________ Probe Number: _______________________ Probe Calibration Date: _________________Total Number of Barns Tested: _________ Number of Barns Passing: _________ How is barn temperature and /or humidity in curing barns monitored? _________________________

CO2 Measurements

BarnID BarnMakeand HeatExchanger Initial Final BarnStatus Number Model Brand Reading Reading Pass / Fail

2 | Curing & Barn Mgmt - Flue.

Curing Facility Records - Flue (Retest Report)

GAPConnectionsCertification--Barn(RETEST)Report

Farmer or Farm Name: ____________________________ Testing Entity: _____________________ Signature of Barn Tester: ___________________________ Date of Testing: ___________________ Barn Location: __________________________________ CO2 Meter Make: __________________ Probe Number: _______________________ Probe calibration date: _________________Total Number of Barns Tested: _________ Number of Barns Passing: _________ How is barn temperature and /or humidity in curing barns monitored? _________________________

CO2 Measurements

BarnID BarnMakeand HeatExchanger Initial Final BarnStatus Number Model Brand Reading Reading Pass / Fail

3 | Curing &

Barn M

gmt - Flue.

Field/Tract HarvestDate Methodof StalkPosition BarnID FuelSource BaleIDNumber(s) ID** Harvesting

HarvestingandCuringRecords-Flue

LP Fuel Oil

Natural Gas Other ________

LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


LP Fuel Oil


TAB 5

Included Records:• NTRM Inspection Information – English & Spanish

• NTRM Inspection Log

Non-Tobacco Related Materials

No

n-T

ob

acco

Re

late

dM

ate

rials

1 | Non-Tobacco Related Materials

NTRM Inspection Information

Non-tobacco related material (NTRM) or foreign matter is a broad term that refers to all materials that are not tobacco lamina and stem. This includes, but is not limited to: soil particles, paper, string, metal fragments, tobacco stalks and suckers, plastics, foam materials, wood, grasses, weeds, oils and burlap fibers, as well as gloves and other personal protection equipment.

Providing a product that is free of all forms of NTRM is a critical aspect of GAP that begins at the farm level with elimination of NTRM sources and physical removal of all NTRM materials during on- farm tobacco handling, storage and transport.

Below is a NTRM inspection checklist. Inspections should be done routinely to ensure new sources of NTRM are addressed as soon as possible.

□ Clean all market prep facilities. Starting the season with a clean facility will make it easier to maintain throughout the entire season.

□ Create designated break areas with space to store gloves, jackets, tools, drinks, or food. These areas should be the only space workers are allowed to eat, drink, and take breaks from market prep activities.

□ Ensure trash cans are emptied regularly, secured to prevent tipping, and in areas easily accessible to employees when they are on breaks.

□ Check facilities for bird’s nest or roosting birds to prevent feathers and bird waste from getting in tobacco.

□ Ensure all the tools used in the market preparation area are in good condition and have handles made of wood or metal.

□ Check and replace any materials used to cover tobacco if fraying or tears are present. When possible use a non-plastic tarp such as canvas or similar quality material.

□ Check to make sure the wagon, trailer, or truck used to transport the tobacco is clean and free from any oil or chemical spills.

Worker Training Tips: • Remind your workers everyday verbally and with posted posters to think about NTRM

prevention. • In training, ask them to use only the designated break areas for eating, drinking, and storage

of other personal items. • Ask them to pick up and place in a trash can any trash or non-tobacco material when they

see it on the market prep floor or near baling supplies.

NTRM Inspection Information

WorkerTrainingTips:


Inspección NTRM

Inspección NTRM Materiales no relacionados al Tabaco (NTRM) o material ajeno al mismo es un término amplio que refiere a todos los materiales que no son el vástago o la lámina del tabaco. Esto incluye, pero no se limita a: partículas del suelo, papel, tiras, fragmentos metálicos, tallos y retoños de tabaco, plásticos, materiales de goma espuma, madera, pastos, hierba mala, aceites y fibras de jute, así como guantes y otros equipos de protección personal.

Proveer un producto libre de todas las formas de NTRM es un aspecto critico de GAP que empieza en la granja a nivel de eliminación de recursos NTRM y remoción física de todos los materiales NTRM durante el manejo, almacenamiento y transporte en la granja.

Adjunta se encuentra una lista de control de inspección de NTRM. Las inspecciones de deben hacer (al menos 1 o 2 veces por semana) para garantizar que las nuevas fuentes de NTRM se aborden lo antes posible.

□ Limpiar las instalaciones de preparación del mercado. Empezar la temporada con unas instalaciones limpias hará el proceso de mantenimiento más fácil durante toda la temporada.

□ Crear áreas designadas para descansos con espacio para guardar guantes, chaquetas/chamarras, herramientas, bebidas, o comida. Estas áreas deben ser el único lugar donde los empleados puedan comer, beber, y tomar descansos fuera de las áreas de preparación del mercado.

□ Asegurar que los botes de basura sean vaciados con regularidad, asegurados para evitar que se volteen, y estar en áreas accesibles para los trabajadores cuando están descansando.

□ Verifique las instalaciones para observar si hay nidos de pájaros, para prevenir que las plumas y desechos de los mismos caigan sobre el tabaco.

□ Asegúrese que todas las herramientas que se usan en el área de la preparación del mercado estén en buenas condiciones y tengan mangos hechos de madera o metal.

□ Observe y reemplace cualquier material usado para cubrir el tabaco si esta deshilachado o rajado. Cuando sea posible use lonas que no sean plásticas, como telas o materiales similares de calidad.

□ Verifique que el vagón, tráiler o camión usado para transportar el Tabaco está limpio y libre de cualquier derrame de aceite o productos químicos.

Consejos de Capacitación para el Personal: • Recuérdele a los trabajadores cada día verbalmente y con carteles para pensar cómo

prevenir NTRM. • En los entrenamientos/capacitaciones, pídales que solo usen las áreas designadas para

comer, beber, y guardar artículos personales. • Pídales que recojan y pongan - basura o materiales no relacionados al tabaco en los

receptáculos provistos cuando lo vean en el piso del área de preparación del mercado o cerca de los suministros de empacado.

ConsejosdeCapacitaciónparaelPersonal:


NTRM Inspection LogRegisstro de Inspección NTRM

Comments(ex: No new sources of NTRM,

added a trash can in break area)

Comentarios(ej: No hay nuevas fuentes deNTRM, se agregó un bote debasura al área de descanso)

Areas Inspected(ex: market prep facilities,

baling equipment, break areas)

Areas Inspeccionadas(ej: instalaciones de

preparación del Mercado,equipos de emaque,áreas de descanso)

WhodidtheInspection?

¿Quién hizzo lainspección?

DateFecha

TAB 6

Included Records:• CPA Inventory Records

• Rainfall Records

• Irrigation Records

• Crop Rotation Records

Copies of the following will be required:• SDS (Safety Data Sheets)

• Agrochemical labels

• Conservation Plan (If Field/Tract ID considered HEL)

Agrochemical Storage and Soil & Water

Ag

roche

mic

al

Sto

rag

e a

nd

So

il & W

ate

r

1 | Agrochemical Storage Soil & Water

CPAInventoryRecords

Reference Brand Name / Product / Common Name Storage Area Amount Number*

*CPA Information Records from Tab 2 IPM and CPA Page 3


Rainfall Records

Field/Tract ID* Date Amount of Crop Condition Precipitation

Rainfall records can be kept daily, weekly or monthly.

*Field/Tract ID from Tab 1 Nutrient Management Records Page 1


Irrigation Records

Field/ Date Source of Application Amount Crop Condition before Irrigating Tract Irrigation Water Type Applied ID*

Irrigation records can be kept daily, weekly or monthly.

*Field/Tract ID from Tab 1 Nutrient Management Records Page 1

4 | Agrochem

ical Storage S

oil & W

ater

Crop Rotation Records

*Field/Tract ID from Tab 1 Nutrient Management Records Page 2** Tillage type indicates one of the following: conventional, strip-till, or minimum till

Field/ Field Tract HEL Crop Tillage Cover Tillage Cover Tillage Cover Tillage Cover ID* (Yes/No) Type** Crop Crop Type** Crop Crop Type** Crop Crop Type** Crop

2016 2017 2018 2019

TAB 7

Included Records:• Labor Numbers

• Worker Recruiting & Hiring Records

• DOL Template of Terms & Conditions of Employment

(English & Spanish) – DOL WH-516

• Worker Termination Record

• Non-Immediate Family Minors Working Record

Copies of the following will be required:• Form I-9

• Terms & Conditions of Employment

• Parental Consent (if non-immediate family minors

(i.e. under 18 on the farm)

• Wage Statements

• If using an FLC:

• Form I-9 for FLC Workers

• FLC Certificate of Registration from DOL

• If authorized to house, Housing Inspection

• If authorized to transport, copy of insurance,

driver’s license, and doctor’s certificate

• FLC Disclosure of Employment/Terms and

Conditions for FLC Workers

• Wage Statements for FLC Workers

Recruiting and Hiring Workers

Re

cru

iting

and

Hirin

gW

ork

ers

Labor Numbers

1 | Recruiting & Hiring Workers

Workers

H-2A Hired by the Grower of Grower AssociationLiving on Farm

Not Living on Farm

H-2A Hired by a H-2ALC (H-2A FLC) Living on Farm

Not Living on Farm

Migrant LaborMigrant Non-H-2A (18 or older)

Migrant Non-H-2A minors (16-17)

Migrant Non-H-2A minors (15)Migrant Non-H-2A minors (14)

Migrant Non-H-2A minors (13 or younger)

Local Labor (non-family, non-H-2A, non-migrant)Local labor (18 or older)

Local minors (16-17)

Local minors (15)

Local minors (14)

Local minors (13 or younger)

Language(s) spoken by workers:

Immediate Family Labor*

Immediate Family (18 or older)

Immediate Family Minors (16-17)

Immediate Family Minors (15)

Immediate Family Minors (14)

Immediate Family Minors (13 or younger)

Number of workersemployed year-round

Number of workersemployed seasonally

Number of workers for whomhousingisprovided

Living onthe Farm

Year-round SeasonallyLiving onthe Farm

Working onthe Farm

Working onthe Farm

*Immediate family members include only: (1) spouse; (2) children, step children, and foster children; (3) parents, stepparents, and foster parents;and (4) brothers and sisters. If the worker doesn not fall into one of these four categories, then the worker is considered a hired worker.

2 | Recruiting &

Hiring W

orkers

WorkerRecruiting&HiringRecords

Collected Discussed Discussed Work Work Emergency Provided Anti- Farm Dateof TypeofLabor Start End Date1-9 Contact Terms& Discrimination Emergency Name Birth Date Date Completed Information Conditions Policy Plan 1/20/1985 Example: John Smith 6/5/19 12/5/19 6/5/2019 3 3 3 3 Under 18

Under 18

Under 18

Under 18

Under 18

Under 18

Under 18

H-2A MigrantFLC LocalFamily







No:

1.

2.

3.

4.

5.

6.

7.


Migrant and Seasonal AgriculturalWorker Protection Act

U.S. Department of LaborWage and Hour Division

OMB NO: 1235-0002 Expires: 08/31/2020

Worker Information—Terms and Conditions of Employment

1. Place of employment: ________________________________________________________________________________________________

2. Period of employment: From _______________________ To ___________________________

3. Wage rates to be paid: $ __________________ per Hour Piece Rate $____________________ per _______________________

4. Crops and kinds of activities: __________________________________________________________________________________________

5. Transportation or other benefits, if any: __________________________________________________________________________________

________________________________________________________________________________________________________________

Charge(s) to workers, if any: __________________________________________________________________________________________

6. Workers’ compensation insurance provided: Yes ________ No _________

Name of compensation carrier: ________________________________________________________________________________________

Name and address of policyholder(s): ___________________________________________________________________________________

________________________________________________________________________________________________________________

Person(s) and phone number(s) of person(s) to be notified to file claim: _________________________________________________________

________________________________________________________________________________________________________________

Deadline for filing claim: ______________________________________________________________________________________________

7. Unemployment compensation insurance provided: Yes _________ No ___________

8. Other benefits: __________________________________________________________________________ Charge(s) _________________

9. For migrant workers who will be housed, the kind of housing available and cost, if any: _____________________________________________

________________________________________________________________________________________________________________

Charge(s) _________________________________________________________________________________________________________

10. List any strike, work stoppage, slowdown, or interruption of operation by employees at the place where the workers will be employed. (If thereare no strikes, etc., enter “None”):

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

11. List any arrangements that have been made with establishment owners or agents for the payment of a commission or other benefits for salesmade to workers. (If there are no such arrangements, enter “None”):

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Name of Person(s) Providing This Information: ______________________________________________________________________________

Note: The Department of Labor–Wage and Hour Division makes this form available in certain other languages to enable employers to satisfy the requirement that the terms and conditions of employment be disclosed in a language common to the workers. Contact the nearest office of the Wage and Hour Division to obtain such forms.

While completion of Form WH516 is optional, it is mandatory for Farm Labor Contractors, Agricultural Employers, and Agricultural Associations to disclose employment terms and conditions in writing to migrant and day-haul workers upon recruitment, and to seasonal workers other than day-haul workers upon request when an offer of employment is made to respond to the information collection contained In 29 CFR §§ 500.75-500.76. This optional form may be used to disclose the required information. Thereafter, any migrant or seasonal worker has the right to have, upon request, a written statement provided to him or her by the employer, of the information described above. This optional form may also be used for this purpose.

We estimate that it will take an average of 32 minutes to complete this collection of information, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Room S3502, 200 Constitution Avenue NW, Washington, D.C. 20210. Do NOT send the completed form to this office.

Persons are not required to respond to this information unless it displays a currently valid OMB number.Optional form WH516 ENG

REV 06/14

5 | Recruiting &

Hiring W

orkers

WorkerName ReasonforTermination Documentation

WorkerTerminationRecord

6 | Recruiting &

Hiring W

orkers

Non-ImmediateFamilyMinors(UnderAge18)WorkingonFarmRecordU.S.Certification: Hired workers under 18 are restricted from Department of Labor (DOL) Hazardous Tasks (ForalistSeeCertificationStandardsAppendix1ListA)

InternationalCertification: Hired workers under 18 are restricted from International Restricted Tasks (ForalistSeeCertificationStandardsappendix1ListB)

Date of Parental Full Name Birth Consent Residence Permanent Address

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

TAB 8

Included Records:• Worker Concern Process Documentation

(English & Spanish)

• Anti-Discrimination Policy

(English & Spanish)

Workers Right & Responsibilities and Worker Concern Helpline

Wo

rke

rsR

ights

&R

esp

onsib

ilities

1 | WRR & WCH

WorkerConcernProcessDocumentation

Worker Concern Process Documentation

Grower ID#

Grower Name

Farm Name

Trainer (s)

Date

• Information on the Worker Rights and Responsibilities and Worker Concern Helpline poster was shared with you and is posted in a place that is visible to all workers.

• You understand the following on this farm: □ The Grower is committed to providing a safe working environment for you

and satisfy your legal rights while you are on this farm. □ A method is available for workers to notify the Grower, orally and in writing,

of any concern related to the terms or conditions of work. □ The Grower will investigate concerns brought forth by workers and provide

notice to the workers, if known, of how the concern will be or was addressed. At the request of the workers, an informal meeting between the Growers and workers will be held to address the concern.

□ If you raise a concern with Grower and are not satisfied with the resolution or handling of the issue, you are encouraged to call the GAP Connections Worker Concern Helpline or legal authority to voice and address the concern.

• The Grower has discussed the following with you concerning the Worker Concern Helpline:

□ If you believe that your legal rights are not being met while working on this farm, and you are not comfortable discussing the issue with someone on this farm, please feel free to call this helpline.

□ Using this helpline will not limit any rights you currently have under U.S. Law, nor limit your ability to share a legal concern you may have with any other person or organization.

□ That the source of any information you provide will be treated as confidential.

□ If you call this helpline and share a concern, the service provider of this helpline will contact you within two weeks to provide an update.

□ You may also choose to remain anonymous when you report your concern. □ If you prefer to remain anonymous, the service provider of this helpline will

give you a number to call in two weeks, so you can receive an update. □ If at any time you feel you are being retaliated against for calling the

helpline, you should call the helpline again and share this with the helpline operator.

Grower ID #

Grower Name

Farm Name

Trainer(s)

Date


Grower ID#

Grower Name

Farm Name

Trainer (s)

Date















Youunderstandthefollowingonthisfarm:

The Grower has discussed the following with you concerningtheWorkerConcernHelpline:


Grower ID#

Grower Name

Farm Name

Trainer (s)

Date















2 | WRR & WCH

DocumentoParaElProcesoDeQuejas

ID del Granjero #

Nombre del Granjero

Nombre de la Granja

Entrenador(es)

Fecha

ID del Granjero #

Nombre del Granjero

Nombre de la Granja

Entrenador(es)

Fecha

• Se le entrego un poster con información de los Derechos y Responsabilidades de los Trabajadores y Línea de Ayuda de Quejas para Trabajadores y esta publicado en un lugar visible a todos.

• Entiende lo siguiente en esta Granja: □ El Granjero está comprometido a proveer un ambiente seguro de trabajo para usted y

satisfacer sus derechos legales mientras se encuentre en la granja. □ Hay un método disponible para notificar al Granjero, oralmente y por escrito, de

cualquier queja relacionada a los términos o condiciones de trabajo. □ El Granjero investigará la queja presentada por el trabajador y notificará a los

trabajadores, si se conoce, como se manejará su queja. A petición de los trabajadores, se hará una reunión entre el Granjero y los trabajadores para tratar la queja.

□ Si usted levanta una queja con el Granjero y no esta satisfecho con la resolución o manejo del problema, se le recomienda que llame a la Línea de Ayuda de Quejar para Trabajadores de GAP Connections o la autoridad legal para expresar y tratar su queja.

• El Granjero ha discutido con usted lo siguiente a cerca de la Línea de Ayuda para Trabajadores: □ Si usted cree que sus derechos legales no están siendo respetados mientras trabaja

en esta granja, y usted no se siente cómodo discutiendo sus problemas con alguien en esta granja, por favor siéntase en la libertad de llamar a esta línea de ayuda.

□ Usar la línea de ayuda no limitara los derechos que tiene bajo las leyes de los Estados Unidos, y tampoco limita su habilidad para compartir una queja legal que tenga con alguna otra persona u organización.

□ Que la fuente de cualquier información que usted aporte será tratada confidencialmente.

□ Si usted llama a la línea de ayuda y comparte una queja, el proveedor de la línea de ayuda le contactara dentro de un plazo de dos semanas para actualizarle.

□ Usted también puede escoger mantenerse anónimo cuando reporte su queja. □ Si usted prefiere mantenerse anónimo, el proveedor de la línea de ayuda le dará un

numero de teléfono al que podrá llamar en dos semanas para recibir una actualización.

□ Si en algún momento siente que se están tomando represalias hacia usted por llamar a la línea de ayuda, usted debe llamar a la línea de ayuda otra vez y compartir esto con el operador de la línea de ayuda.

Documento Para El Proceso De Quejas

EntiendelosiguienteenestaGranja:

ElGrannjerohadiscutidoconustedlosiguienteacercadelaLineadeAyudaparaTrabajadores:

ID del Granjero #

Nombre del Granjero

Nombre de la Granja

Entrenador(es)

Fecha
















ID del Granjero #

Nombre del Granjero

Nombre de la Granja

Entrenador(es)

Fecha
















WorkerConcernProcessDocumentationDocumentoParaElProcesoDeQuejas

3 | WRR & WCH

Printed Name (Nombre Impreso) Signature (Firma)

1 .

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18

19

20

Sign below if you understand the Worker Concern Process being used on this farm.

Firme abajo si usted entendió el Proceso de Quejas para Trabajadores usado en esta granja.

Anti-Discrimination Policy

4 | WRR & WCH

* _______________________________________ is an equal opportunity employer and makes all

employment decisions without regard to race, color, age, religion, sex, disability, genetic information,

national origin, and other situations protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including but not limited to; compen-

sation,hiring,placement,promotion,termination,layoff,recall,transfer,leavesofabsence,benefits,

and training.

* _______________________________________ seeks to comply with all applicable federal, state

and local laws related to discrimination.

* _______________________________________ makes decisions concerning employment

basedstrictlyonanindividual’squalificationsandabilitytoperformthejobunderconsideration,

thecomparativequalificationsandabilitiesofotherapplicantsoremployees,andtheindividual’s

past performance.

If you believe that an employment decision has been made that does not conform with

* ___________________________________________________________________________

commitment to equal opportunity, you should promptly bring the matter to the attention of

* ___________________________________________________________________________

for an equitable resolution.

Therewillbenoretaliationagainstanyemployeewhofilesacomplaintingoodfaith,eveniftheresult

oftheinvestigationproducesinsufficientevidencetosupportthecomplaint.

*INSERT FARM NAME OR GROWER NAME

Politica Antidiscriminación Borrador

5 | WRR & WCH

* _______________________________________ es un empleador de oportunidades equitativas

y hace todas las decisiones de empleo sin importar la etnicidad, color, edad, religión, sexo, disca-

pacidades, información genética, nacionalidad, y otras situaciones protegidas por las leyes locales,

estatales y federales.

Esta política es implementada para todos los términos y condiciones de empleo, incluyendo, pero

no limitado a; compensación, contratación, colocación, promoción, despidos, reducción de personal,

revisión,transferencia,permisosparaausentarse,beneficios,yentrenamiento.

* _______________________________________ busca cumplir con las leyes locales, estatales y

federales relacionadas a la discriminación.

* _______________________________________ toma decisiones en cuanto a empleo basado

estrictamenteenlascalificacionesindividualesylascapacidadesderealizaruntrabajobajo

consideración,lascalificacionescomparativasyhabilidadesdeotrosaplicantesoempleados,

y actuaciones pasadas del individuo.

Si usted cree que se ha tomado una decisión de empleo que no está de acuerdo con el compromiso

de * ___________________________________________________________________________

de oportunidades equitativas, debe reportar el asunto lo más pronto posible a

* ___________________________________________________________________________

para una resolución equitativa..

No habrá represalias en contra de ningún empleado que presente una queja en buena fe, inclusive si

elresultadodelainvestigaciónnotienesuficientespruebasqueapoyenlaqueja.

*NOMBRE DE LA GRANJA O AGRICULTAR

TAB 9

Included Records:• DOL Template Housing Terms & Conditions

(DOL WH-521)

• Vehicle Information Records

• Driver Information Records

• Vehicle Inspection Log

Copies of the following will be required:• Housing Inspection Certificate

Housing, Sanitation and Transportation

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usin

g,

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tion a

nd

Tra

nsp

orta

tion

1 | Housing, Sanitation & Transportation

2 | Housing, S

anitation & Transportation

Vehicle Make/Model Year Annual Checklist

Vehicle Information

Valid Tags InsuranceIf required: State Safety Inspection, Date: __________ Federal Safety Inspection, Date: ________





3 | Housing, S

anitation & Transportation

DriverInformation

Driver License Date on Doctor Driver’sName DriverLicenseNumber ExpirationDate Certificate IfFLCorFLCE

CertificateAuthorized to transport (FLC Only)

Authorized to drive


Authorized to drive


Authorized to drive


Authorized to drive


Authorized to drive


Authorized to drive


Authorized to drive


Authorized to driveCertificateAuthorized to transport (FLC Only)

Authorized to drive


Vehicle Inspection Log


Vehicle Inspection Log

Vehicle _____ Vehicle _____ Vehicle _____ Vehicle _____ Vehicle _____

Date ______ Date ______ Date ______ Date ______ Date ______ “ 3” “ 3” “ 3” “ 3” “ 3”

Head Lights

Stop Lights

Tail Lights

Back up Lights

Hazard Warning Lights

Turn Signals

Brakes (free of leaks and parkingbrake functional)

Windshield (free of cracks)

Windshield Wipers (operational)

Floors/Sides (passenger compartmentfree of openings or defects)

Seats (securely fastened)

Exiting Capability (properly functioningdoor handles and latches)

Fire Extinguishers

Flares/Reflectors/Lanterns

Tires (tread and equal size)

Steering (safe and accurate)

Horn

Ventilation (Windows operational)

Mirrors (full vision of sides and rear)

Fuel System (free of leaks, cap secure)

Exhaust System (free of leaks, dischargeaway from passenger compartment)

Comments:

Maintenance:

TAB 10

Included Records:• OSHA Form 300, Form 300A, and Form 301

• How to Prepare for an Emergency or Disaster

(English & Spanish)

• Emergency Response Plan

(English & Spanish)

• Farm Roster

(English & Spanish)

• List of Important Numbers

(English & Spanish)

• In Case of Medical Emergency

(English & Spanish)

• In Case of a Fire Emergency

(English & Spanish)

• In Case of Severe Weather/Tornado Sheltering

(English & Spanish)

• Worker Safety Training Records

• Worker Crop Integrity Training Records

Worker Training and Farm Safety

Wo

rkin

g

Tra

inin

g a

nd

Farm

Safe

ty

1 | Worker Training &

Farm S

afety

U.S. Department of LaborOccupational Safety and Health Administration

OSHA’s Form 300 (Rev. 01/2004) Year 20__ __Log of Work-Related Injuries and IllnessesYou must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed healthcare professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free touse two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on thisform. If you’re not sure whether a case is recordable, call your local OSHA office for help.

Form approved OMB no. 1218-0176

Page ____ of ____

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Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Page totals

Establishment name ___________________________________________

City ________________________________ State ___________________

Injury

Enter the number ofdays the injured orill worker was:

Check the “Injury” column orchoose one type of illness:

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

month/day

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to reviewthe instructions, search and gather the data needed, and complete and review the collection of information. Persons are not requiredto respond to the collection of information unless it displays a currently valid OMB control number. If you have any commentsabout these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of StatisticalAnalysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.

(A) (B) (C) (D) (E) (F)

(M)

(K) (L)(G) (H) (I) (J)

DeathDays awayfrom work

On jobtransfer orrestriction

Awayfromwork

Attention: This form contains information relating toemployee health and must be used in a manner thatprotects the confidentiality of employees to the extentpossible while the information is being used foroccupational safety and health purposes.

CHECK ONLY ONE box for each casebased on the most serious outcome forthat case:

Job transferor restriction

Other record-able cases

Remained at Work

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Injury

Identify the person Describe the case Classify the case

Case Employee’s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body affected,

of illness or made person ill (

no. or onset and object/substance that directly injured

e.g., Second degree burns on

e.g., Welder e.g., Loading dock north end

right forearm from acetylene torch

( ) ( )

)

_____ ________________________ ____________ ______/__________ ______________________ ___________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ___________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ___________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ___________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ___________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ___________________ ____________________________________________________ ____ ____

_____ ________________________ ____________ ______/__________ ______________________ ____________________________________________________ ____ ____

days days

days days

days days

days days

days days

days days

days days

days days

days days

days days

days days

days days

days days


Farm S

afety


OSHA’s Form 300A (Rev. 01/2004)Year 20__ __

Summary of Work-Related Injuries and IllnessesForm approved OMB no. 1218-0176

Total number ofdeaths

__________________

Total number ofcases with daysaway from work

__________________

Number of Cases

Total number of days awayfrom work

___________

Total number of days of jobtransfer or restriction

___________

Number of Days

Post this Summary page from February 1 to April 30 of the year following the year covered by the form.

All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log

to verify that the entries are complete and accurate before completing this summary.

Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you’ve added the entries from every page of the Log. If you

had no cases, write “0.”

Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or

its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.

Establishment information

Employment information

Your establishment name __________________________________________

Street _________________________ _______

City ____________________________ State ______ ZIP _________

Industry description ( )

_______________________________________________________

Standard Industrial Classification (SIC), if known ( )

____ ____ ____ ____

North American Industrial Classification (NAICS), if known (e.g., 336212)

e.g., Manufacture of motor truck trailers

e.g., 3715

(I ee the

Worksheet on the back of this page to estimate.)

_____________________

OR

____ ____ ____ ____ ____ ____

Annual average number of employees ______________

Total hours worked by all employees last year ______________

f you don’t have these figures, s

Sign here

Knowingly falsifying this document may result in a fine.

I certify that I have examined this document and that to the best of myknowledge the entries are true, accurate, and complete.

___________________________________________________________

___________________________________________________________

Company executive Title

Phone Date( ) - / /

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instructions, search and gather the data needed, andcomplete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have anycomments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,Washington, DC 20210. Do not send the completed forms to this office.

Total number of . . .

Skin disorders ______

Respiratory conditions ______

Injuries ______

Injury and Illness Types

Poisonings ______

Hearing loss

All other illnesses ______

______

(G) (H) (I) (J)

(K) (L)

(M)(1)

(2)

(3)

(4)

(5)

(6)

Total number ofcases with jobtransfer or restriction

__________________

Total number ofother recordablecases

__________________


Farm S

afety

Information about the employee

Information about the physician or other health careprofessional

Full name

Street

City State ZIP

Date of birth

Date hired

Male

Female

Name of physician or other health care professional

If treatment was given away from the worksite, where was it given?

Facility

Street

City State ZIP

Was employee treated in an emergency room?

Yes

No

Was employee hospitalized overnight as an in-patient?

Yes

No

_____________________________________________________________

________________________________________________________________

______________________________________ _________ ___________

______ / _____ / ______

______ / _____ / ______

__________________________

________________________________________________________________________

_________________________________________________________________

_______________________________________________________________

______________________________________ _________ ___________

�

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OSHA’s Form 301Injury and Illness Incident Report

Form approved OMB no. 1218-0176

This is one of the

first forms you must fill out when a recordable work-

related injury or illness has occurred. Together with

the and the

accompanying these forms help the

employer and OSHA develop a picture of the extent

and severity of work-related incidents.

Within 7 calendar days after you receive

information that a recordable work-related injury or

illness has occurred, you must fill out this form or an

equivalent. Some state workers’ compensation,

insurance, or other reports may be acceptable

substitutes. To be considered an equivalent form,

any substitute must contain all the information

asked for on this form.

According to Public Law 91-596 and 29 CFR

1904, OSHA’s recordkeeping rule, you must keep

this form on file for 5 years following the year to

which it pertains.

If you need additional copies of this form, you

may photocopy and use as many as you need.

Injury and Illness Incident Report

Log of Work-Related Injuries and Illnesses

Summary,

Information about the case

Case number from the

Date of injury or illness

Time employee began work

Time of event Check if time cannot be determined

Date of death

Log _____________________ (Transfer the case number from the Log after you record the case.)

______ / _____ / ______

____________________

____________________

______ / _____ / ______

AM / PM

AM / PM �

What was the employee doing just before the incident occurred?

What happened?

What was the injury or illness?

What object or substance directly harmed the employee?

If the employee died, when did death occur?

Describe the activity, as well as the

tools, equipment, or material the employee was using. Be specific. “climbing a ladder while

carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”

Tell us how the injury occurred. “When ladder slipped on wet floor, worker

fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker

developed soreness in wrist over time.”

Tell us the part of the body that was affected and how it was affected; be

more specific than “hurt,” “pain,” or sore.” “strained back”; “chemical burn, hand”; “carpal

tunnel syndrome.”

“concrete floor”; “chlorine”;

“radial arm saw.”

Examples:

Examples:

Examples:

Examples:

If this question does not apply to the incident, leave it blank.

Completed by

Title

Phone Date

_______________________________________________________

_________________________________________________________________

(________)_________--_____________ _____/ ______ / _____

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the

collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,

Washington, DC 20210. Do not send the completed forms to this office.

10)

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Attention: This form contains information relating toemployee health and must be used in a manner thatprotects the confidentiality of employees to the extentpossible while the information is being used foroccupational safety and health purposes.

Growers can follow these steps below and use the provided Emergency Disaster Plan template to prepare for unexpected emergencies or disasters on their farming operations.1. Plan carefully.2. Identify the risks on Your operation.3. Put emergency procedures in place.4. Create a communication plan.5. Practice for all kinds of emergencies.

Planning includes considering man-made and natural disasters. Decide how you will assess the situation and use available resources to take care of yourself, family, workers and property in the case of an emergency or disaster. It is also important to review insurance policies annually to ensure they meet your coverage needs in case of an emergency or disaster.

Determine which disasters are most common in your area including but not limited to: Fire Tornado Hurricane SevereWeather(i.e.awarenessofthepresenceoflighteningwhenworkinginfields) Flooding Earthquake Medical/Accident Explosions Biological (i.e. human or animal disease outbreak) Chemical/Hazardous Material Spill and/or Human Exposure

Carefully assess how the farm functions, determine the information, workers, materials and equip-ment that are necessary to keep operating after an emergency or disaster. The following are sug-gestions to help in preparing emergency procedures.

Create a list of important numbers for emergency services, utilities, service providers, medical providers, veterinarians, insurance companies, etc. Identify a safe shelter and/or create an evacuation plan. Prepareformedicalemergenciesbykeepingfirstaidkitsclosebyandbypostingphone numbersforemergencyresponderssuchaspolice,EMS,firedepartmentandothers. Create a map or description of building site including utility lines and where CPA’s or fuel tanks are located. Create a list of equipment. Ensure that you have a backup of payroll & accounting systems. Maintain storage of important paper documents (such as insurance policies) off site. Develop and maintain an Emergency Supply Kit. Equipbuildingsandfacilitieswithsafetyandemergencygearsuchasfireextinguishers, smokeandheatdetectors/alarms,flashlightsandbatteries,batterypoweredradiosand weatherradiosandelevateequipmentoffthefloortoavoidelectricalhazards.

4 | Worker Training & Farm Safety

HowtoPrepareforanEmergencyorDisaster

1. Plan Carefully

2. Identify the Risks on your Operation

3.PutEmergencyProceduresinPlace


HowtoPrepareforanEmergencyorDisaster

Communication is important tool in your emergency plan. A communication plan helps ensure every-one knows how to reach each other and where to meet in an emergency. Mobile phones and comput-ers could be unreliable during or after a disaster, as well as, electricity could be disrupted.Plan for extended disruptions and carefully examine which utilities are vital to the operation. Talk with service providers about potential alternatives and identify back-up options such as portable genera-tors. Have a written copy of all phone numbers and email address of workers and family on the farm and decide on a safe and familiar place for workers and family on the farm to go for protection or to reunite. Identify the following meet up places:

• Indoor - If you live in an area where tornadoes, hurricanes or other weather can happen, make sure everyone knows where to go for protection. • IntheNeighborhood-Aplacewhereeveryonecanmeetifthereisafireorotheremergency and need to leave the residence or farm. • Outside of the Neighborhood -A place to meet if a disaster happens and everyone is not able to get back to the home or farm. • Outside of your Town or City - A place to meet when everyone is outside of the neighborhood and outside of your town/city locations are in an evacuation area.

The best method of preparation for a disaster is to talk to your employees. A good plan is only as good as the workers’ awareness and understanding of the plan.

Conduct education and training for workers and family on the farm with information on disaster preparedness skills. Plan to conduct evacuation drills and other emergency exercises together. Talkwithfirstresponders,emergencymanagers,communityorganizationsandutilityproviders so they are aware and familiar with the farm and include them in emergency/disaster drills on the farm. Annually review the farm emergency/disaster plan and update as the changes occur. Make sure employees are trained annually and new employees are familiar with the plan.

The following pages are templates that can be used by growers to prepare for an emergency ordisaster.Postthesepageswhereworkerscanviewthemeasilyorhavetheminalocationwhere all workers know where they are and an access them at any time.

FOR MORE INFORMATION ON DISASTER OR EMERGENCY PREPAREDNESS GO TO WWW.READY.GOV

4. Create a Communication Plan

5.PracticeforAllKindsofEmergencies


Los productores pueden seguir los pasos siguientes y usar la plantilla proporcionada del Plan de Emergencia de Desastres para prepararse para las emergencias inesperadas o desastres en sus operaciones agricolas.1. Planee cuidadosamente.2. ldentifiquelosriesgosdesusactividadesenlalistaacontinuaci6nuotrosrecurses.3. Ponga en marcha procedimientos de emergencia.4. Cree un plan de comunicaci6n.5. Practique ejercicios para todo tipo de emergencia.

Planear incluye considerar desastres naturales y creados por el hombre. Decida coma evaluaria la situaci6n y usaria los recurses disponibles para cuidarse a si mismo, la familia, trabajadores, y propiedad en el caso de una emergencia o desastre. Tambien es importante revisar las p61izas de seguro anualmente y asegurarse que cumpla con la cobertura necesaria en caso de una emergen-cia o desastre.

Determine cuales desastres son los mas comunes en su area incluyendo, pero no limitado a: lncendio D Tornado Huracan Clima lnclemente ( ej. conciencia de la presencia de rayos cuando se trabaja en los campos ) lnundaci6n Terremoto Medico/Accidente Explosion es Biol6gico (ej. brote de enfermedad humana o animal ) Quimico /Derrame de Material Peligroso y/o Exposici6n Humana

Cuidadosamente evalue como funciona su granja, determine la informaci6n, trabajadore s, materiales yequipo que son necesarios para mantenerse operando despues de una emergenciao desastre. Las siguientes sugerencias le ayudaran a preparar procedimientos de emergencia.

Crear una lista de numeros importantes para servicios de emergencia, proveedores de servicios publicos , proveedores medicos, veterinarios, compa iiia de seguros, etc.

ldentificarunrefugioSeguray/ocrearunplandeevacuaci6n. Prepararse para emergencias medicas, teniendo cerca un botiquin de primeros auxilios y publicando los numeros de emergenciacomo la policia, EMS (Servicios de Emergencias medicas ) , departamento de bomberos y otros. Hagaunmapaconladescripci6ndeledificioincluyendolaslineasdelosserviciospublicosy donde se encuentran ubicadoslos tanques de gasolina o CPA’s. Haga una lista de los equipos. Asegurese de tener una co pia de seguridadde los sistemas de n6mina y contabilidad. Almacene documentos importantes (coma p61izas de seguros) fuera del sitio. Desarrolle y mantenga un Kit con Suministros de Emergencia. Equipelasinstalacionesyedificiosconequiposdeseguridadcomoextinguidoresdeincendio, detectores/alarmas de calor e incendios, linternas y baterias , radios de baterias y radios del clima, y eleve todos los equipos del suelo para evrtar un peligro electrico.

Como p-bep-ababse p-abu emebge C10 Desastre

1. Planee Cuidadosamente

2.IdentifiqueLosRiesqosDeSusActividades

3.PongaenMarchaProcedimientosdeEmergencia


ComoPrepararseparaunaEmergenciaodeSastre

CLa comunicaci6n es una herramienta importante en su plan de emergencia. Un plan de comuni-caci6n de emergencia le ayuda a asegurarse que todos sepan c6mo llegar a los demas y donde reunirse en caso de una emergencia. Los telefonos celulares y las computadoras pueden ser poco confiablesduranteodespuesdeundesastre,tantocomo,laelectricidadpuedefallar.Planee para la interrupci6n prolongada y cuidadosamente examine cuales servicios publicos son vitales para la operaci6n. Hable con los proveedores de dichos servicios a cerca de alternativas e identifiqueopcionescomogeneradores.Tenga una copia escrita con todos los numeros de telefonos y direcciones electr6nicas de todos lostrabajadores y familias en la granja y escoja un lugar seguro y familiar para los trabajadores y famili-asenlagranjaparareunirseyestarprotegidos.ldentifiqueloslugaresdereunion: Interior - Si vive en un area de tornados, huracanes u otros climas pueden suceder, asegurese que todos sepan a donde ir por protecci6n. En el vecindario - Un lugar d onde todos puedan encontrarse si hubiera un incendio u otra emergencia y necesitan evacuar la residencia o la granja Fuera del vecindario - Un lugar donde encontrarse si pasara un desastre y no pueden regresar a la casa o la granja Fuera del pueblo o ciudad - Un lugar donde encontrarse cuando todos estan fuera del vecindario y lugares fuera del pueblo/cuidad que esten en un area de evacuaci6n.

TEl mejor metodo de preparaci6n para un desastre es hablar con sus empleados. Un buen plan solamente sera bueno si todos los trabajadores entienden y estan conscientes del plan.

Eduque y entrene a los trabajadores y las familias en la granja para prepararlos con informaci6n y destrezas en desastres. Hagan ejercicios para conducir un plan de evacuaci6n y otros ejercicios de emergencias juntos. Hable con los cuerpos de emergencias, jefes de emergencias, organizaciones comunitarias, proveedores. de servicios publicos para que ellos esten al tanto y conozcan la granja e incluyalos en los ejercicios de emergencia/desastres en la granja. Revise los planes de emergencia/desastres anualmente y actualicelos cuando ocurran cambios. Asegurese que sus empleados sean entrenados anualmente y que los nuevos empleados esten. familiarizados con el plan.

Las siguientes paginas son plantillas que pueden usar los granjeros para prepararse para una emergenciaodesastre.P6ngalasdondelostrabajadorespuedenverlosfacilmente,sepand6nde estan, y puedan acceder en cualquier momento.

PARA MAS INFORMACION EN PREPARACION DE DESASTRES O EMERGENCIA DIRIJASE AWWW.READY.GOV

4. Haga un plan de emergencia

5. Practique para todo tipo de emergencias


EmergencyResponsePlan

Farm Name:

Address:

Telephone:

Contact Name:

Last Revision Date:

Employees will be warned to evacuate thebuilding, site, or area using the following system:

Person who will bring the farm roster to theevacuatoin assembly area to account everyone:

If an evacuation required, everyone shouldassemble at the following location for roll call:

PlandeRespuestadeEmergencia

Nombre de la Finca:

Direccion:

Telefono:

Responsable

Fecha de laultima revision:

Seusarael siguiente sistema para advertir a los empleados que deben evacuar el lugar oarea:

La siguiente personatraera la lista de la granja al lugar de encuentro para contarlos a todos:

Si serequiere una evacuaci6n todos deben encontrarse en el siguiente lugar para ser contados:

Is special assistance needed Name Phone for this person (i.e. Person with disability)


Farm Roster


ISe necesita asistencia Nombre Telefono especial para esta persona (ej. persona con discapacidad)?

Lista de la Ganja


List of Important Numbers

Emergency Name Emergency Non-Emergency Service Telephone Telephone

Fire Department

Emergency MedicalService

Police Department

Emergency Management Agency

Hospital

Public Health Department

State EnvironmentalAuthority

National ResponseCenter (EPA)

Electrician

Plumber

Fire Protection Contractor

Hazardous MaterialsCleanup

Cleanup/DisasterRestoration


Lista de Numeros Importantes

Serviciade Telefonode Telefonodeno Emergencia Nombre Emergencia Emergencia

Departmento deBomberos

Servicios deEmergencia Medica

Departamento dePolicias

Agenciade Manejo deEmergencia

Hospital

Departamento deSalud Publica

Autoridad Estatal delAmbiente

Centro Nacional deRespuesta (EPA)

Electricista

Pbmero

Contratista deProtecci6n de Incendios

Lipieza de MaterialesPeligrosos

Limpieza/Restauraci6nde Desastres


In Case of Medical Emergency

1. If a medical emergency is reported, dial 9-1-1 and request an ambulance. Provide the following information:

• Number and location of victim(s)

• Nature of injury or illness

• Hazards involved

• Nearest emergency access point (entrance)

2. Alert those trained (members of the medical response team if no one is trained on the farm) to respond to the victim's location and bring a first aid kit or AED. Only trained responders should provide first aid assistance.

3. Do not move the victim unless the victim's location is unsafe. 4. Control access to the scene. 5. Take "universal precautions" to prevent contact with body fluids and exposure to bloodborne

pathogens. 6. Meet the ambulance at the nearest entrance or emergency access point; direct them to the

victim(s).

List of those trained to administer first aid, CPR, or use automated external defibrillator (AED)

Name Contact Number(s)

Locations of first aid kits and automated external defibrillator(s) (AEDs)

Locations of First Aid Kits

Locations of Automated External Defibrillator(s) (AEDs)

InCaseofMedicalEmergency


InCasodeUnaEmergenciaMedica

1. Sise reporta umemergenciamedica, marque al 9-1-1 y pida una ambulancia

Provea la siguiente informaci6n :

• Numero y ubicaci6n de la(s) victima(s)

• Naturaleza de lalesi6n y enfermedad

• Si hay material peligroso

• Punto de accesomas cercano a la emergencia (entrada)

2. Alerte a aquellos que han sido entrenados (miembros del equipo de respuesta medica sino ha sido

entrenado ninguno en la granja) para responder al lugar donde se encuentra la victima y traer el equipo

de primeros auxilios a AED. Unicamente los entrenados deben proporcionar asistencia de primeros

auxilios.

3. No mueva a lavictimaa menos que lavictimase encuentre en un lugar inseguro.

4. Controle el acceso a la escee1a.

5. Tome las "precauciones universales" para prevenir el contacto con fluidos corporales y la exposici6na

los pat6genos trasmitidos por la sangre.

6. Recibaa laambulanciaen la entradamascercana o acceso de emergencia cercano, dirijale a la(s)

victima(s).

Lista de aquellos entrenados para suministrar primeros auxilios, CPR o parar usa el desfibrilador externo

automatico(AED)

Nombre Nombre(s) y Numero(s) de los Responsables

Ubicaci6nde los equipos de primeros auxilios y el/los desfibriladores (es)automatico(s)(AEDs)

Ubicaci6nde los equipos de primeros auxilios

Ubicaci6ndel/los equipo (s) destibrilador(es)automatico(s)

(AEDs)


InCaseofaFireEmergency

InCaseofSevereWeather/TornadoSheltering

In Case of a Fire Emergency 1. If a fire is reported, pull the fire alarm (if available and not already activated) to warn

everyone to evacuate.

2. Dial 9-1-1 to alert the fire department.

Provide the following information:

• Name of person reporting fire

• Telephone number for a return call

• Farm Name and Street Address

• Nature of fire

• Fire location (building, barn, field, house equipment, etc.)

3. Evacuate people to a primary assembly area outside.

4. Account for all family and workers at the assembly area (use List of Individuals on the Farm).

5. Meet the fire department when they arrive and inform fire department commander if everyone has been accounted for and if there are any injuries.

6. Provide an update on the nature of the emergency and actions taken.

7. Provide building layout, map of site, etc. and other assistance as requested.

In Case of Severe Weather/Tornado Sheltering 1. Identify location of tornado shelter(s)

2. If a tornado warning is issued instruct everyone to move to shelter

Severe Weather/Tornado Shelter Locations

3. Assign someone the following responsibilities in advance of severe weather:

Shelter-in-place Team Assignments Name

Person to monitor weather sources for updated

emergency instructions and broadcast warning if

issued by weather services

Person(s) to direct people to designated tornado

shelter(s)








• Nature of fire
















shelter(s)








• Nature of fire
















shelter(s)


EnCasodeUnaEmergenciaporIncendio

EnCasodeUnaEmergenciaporIncendio

EN CASO DE UNA EMERGENCIA POR INCENDIO

1. Sise reporta un incendio, active la alarma (siestadisponible y no ha sido previamente activada) para alertar a todos que debenevacuar.

2. Marque 9-1-1 para reportarlo al departamento de bomberos. Provea la siguiente informaci6n:

• Nombre de la persona reportando el incendio

• Numero de telefono para recibir llamadas

• Nombre y Direcci6n de la finca

• Naturaleza del incendio

• Ubicaci6n del incendio (edificio, granero, campo, casa, equipo, etc.)

3. Evacuar a las personas al area de reunion en el exterior. 4. Cuente a todas las familiasy trabajadores en el area de reunion (use la lista de los individuos en la

granja). 5. Reciba al departamento de bomberos cuando lleguene informele al comandante si todos han sido

contados y si hayalg(m herido. 6. De un informe de la naturaleza de la emergencia y las acciones a seguir. 7. Provea un diseno del edificio, un mapa del sitio y cualquier otra asistencia requerida.

EN CASO DE UNA EMERGENCIA POR INCENDIO 1. ldentifique el/los refugio(s) 2. Si se emite una alerta de tornados aviselea todos que se vayan al refugio

Ubicacionde Refugio de Tornado/Clima Severo

3. Asigne con tiempo a alguien para las siguientes responsabilidades en caso de clima severo:

Equipo Asignado para las tareas en el refugio Nombre

Persona que monitorea las fuentes del clima para

instrucciones actualizadas de emergencia y

comunicar alertas si son emitidas por el servicio

meteorol6gico

Personas paradirigir a las personas alAos refugios de

tornado(s)

EN CASO DE UNA EMERGENCIA POR INCENDIO

1. Sise reporta un incendio, active la alarma (siestadisponible y no ha sido previamente activada) para alertar a todos que debenevacuar.

2. Marque 9-1-1 para reportarlo al departamento de bomberos. Provea la siguiente informaci6n:

• Nombre de la persona reportando el incendio

• Numero de telefono para recibir llamadas

• Nombre y Direcci6n de la finca

• Naturaleza del incendio

• Ubicaci6n del incendio (edificio, granero, campo, casa, equipo, etc.)

3. Evacuar a las personas al area de reunion en el exterior. 4. Cuente a todas las familiasy trabajadores en el area de reunion (use la lista de los individuos en la

granja). 5. Reciba al departamento de bomberos cuando lleguene informele al comandante si todos han sido

contados y si hayalg(m herido. 6. De un informe de la naturaleza de la emergencia y las acciones a seguir. 7. Provea un diseno del edificio, un mapa del sitio y cualquier otra asistencia requerida.

EN CASO DE UNA EMERGENCIA POR INCENDIO 1. ldentifique el/los refugio(s) 2. Si se emite una alerta de tornados aviselea todos que se vayan al refugio

Ubicacionde Refugio de Tornado/Clima Severo

3. Asigne con tiempo a alguien para las siguientes responsabilidades en caso de clima severo:

Equipo Asignado para las tareas en el refugio Nombre

Persona que monitorea las fuentes del clima para

instrucciones actualizadas de emergencia y

comunicar alertas si son emitidas por el servicio

meteorol6gico

Personas paradirigir a las personas alAos refugios de

tornado(s)


WorkerSafetyTrainingRecords

Worker Safety Training Records

Farm Name:

Source of Training:

□ Verbal Discussion

□ Training Video

□ Tailgate Training Kits

□ Farm Safety & Compliance Event

Trainer Name: Date:

The following Worker Safety and Training Topics have been presented and discussed:

Se han presentado y discutido los siguientes temas de Seguridad y Formación Laboral:

□ Prevention of Carbon Monoxide Poisoning (Fire-Cured Only)

□ General Farm Safety

□ Safe Operation of Farm Equipment and Machinery

□ Green Tobacco Sickness – Symptoms & Treatments

□ Heat Stress – Symptoms & Treatments

□ Storage, Handling, Application & Disposal of Agrichemicals

□ Use of Personal Protective Equipment (PPE)

□ Recognition of Restricted Entry Interval (REI)

□ Required Worker Protection Standard Training

□ Farm Emergency Plan & Emergency Response

□ Prevención de la Intoxicación por Monóxido de Carbono (Solo Curado al Fuego)

□ Seguridad General de la Granja

□ Operación Segura de Maquinaria y Equipos Agrícola

□ Enfermedad del Tabaco Verde - Síntomas & Tratamientos

□ Estrés por el Calor - Síntomas & Tratamientos

□ Almacenamiento, Manejo, Aplicación & Eliminación de Agroquímicos

□ Uso de Equipo de Protección Personal (PPE)

□ Reconocimiento del Intervalo de Entrada Restringida (REI)

□ Capacitación Estándar Requerida para la Protección del Trabajador

□ Plan de Emergencia Agrícola y Respuesta de Emergencia

By signing below, the employee agrees to having received this training and understands the dangers

associated.

Al firmar abajo, el empleado está de acuerdo en que ha recibido el entrenamiento y entiende el riesgo asociado.

Printed Name (Nombre impreso) Signature (Firma)

1

2

5

6

7


Farm Name:

Source of Training:


□ Training Video



Trainer Name: Date:
























associated.



1

2

5

6

7


Farm Name:

Source of Training:


□ Training Video



Trainer Name: Date:
























associated.



1

2

5

6

7

Printed Name (Nombre Impreso) Signature (Firma)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


WorkerCropIntegrityTrainingRecords

Worker Crop Integrity Training Records

Farm Name:

Source of Training:


□ Training Video



Trainer Name: Date:

The following Worker Crop Integrity Training Topics have been presented and discussed:

Se han introducido los siguientes temas de información de integridad de cultivos y se han examinado:

□ Grade Separation (Air & Fire Only)

□ Proper Baling and Market Separation

□ NTRM Prevention

□ Harvesting Tobacco

□ Separación de la Categoría (Solo Aire & Fuego)

□ Embalado Adecuado y Separación del Mercado

□ Prevención del NTRM

□ Cosecha del Tabaco


associated.



1

2

3

4

6

7

8

9

10


Farm Name:

Source of Training:


□ Training Video



Trainer Name: Date:





□ NTRM Prevention







associated.



1

2

3

4

6

7

8

9

10


Farm Name:

Source of Training:


□ Training Video



Trainer Name: Date:





□ NTRM Prevention







associated.



1

2

3

4

6

7

8

9

10

2019 required record checklist - gap connections flue_gapc... · 2019-01-03 · 2 2019 required...

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