School Pesticide Use Questionnaire

Name and title of person (or persons) filling out this form:

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School or school district: _________________________________________________________________________

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(Please use the back of this page or additional sheets of paper if necessary to answer these questions.)

1. Pesticide Use Policy: Does the school or school district have a written pesticide use policy? __________ If so, please attach a copy.

Does this policy govern indoor/structural pesticide use? _______ Outdoor/landscape pesticide use? _________

2. Pest Control Personnel and Training: Is pest control a contracted or "in-house" function (or both)? Please explain:

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If it is contracted, please attach a copy of the contract specification or specifications.

Please list the contractor(s), if any. _________________________________________________________________

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Are all the pesticide applicators hired (or contracted for) by the district licensed? ______________________________

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Do seasonal employees, custodians, or school nurses ever apply pesticides? _________________________________

How many licensed applicators does the district employ? ________________________________________________

3. Pest Control Methods: What measures does the district use, if any, to prevent or control the following potential "pests"? Please describe either pesticide applications or non-chemical techniques:

Broadleaf weeds (in lawns, shrub beds, athletic turf, pavement cracks, ball diamonds, running tracks, gardens, under new pavement, or when new landscapes are installed):

Poison oak or ivy:

Blackberries:

Grasses (in shrub beds, along fencelines, along building foundations and curbs, in pavement cracks, in ball diamonds, in mulched play areas, around the base of trees, etc.):

Clover:

Moss (on pavement, on roofs):

Other "weeds"? (please list):

Head lice:

Stinging insects (yellowjackets, bees, wasps, mosquitoes):

Ants (house ants, sugar ants, moisture ants, fire ants):

Carpenter ants:

Termites:

Other wood destroying insects (in wooden play equipment, in fence posts):

Cockroaches:

Rodents (rats, mice, gophers, moles):

Fleas:

House flies or fruit flies:

Silverfish:

Meal moths:

Spiders:

Fungus:

Mold and mildew:

Birds (pigeons, starlings):

Tree or plant diseases (anthracnose, Dutch elm disease, others?):

Aphids:

Any other pests (please list):

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4. Pesticide Use Records: If pesticides* are used, what kind of records are kept of applications?

* including insecticides, herbicides (weed-killers), fungicides, rodenticides, wood preservatives, moss-killers, soil sterilants, repellants, certain baits and lures, or other products licensed to kill, control or repel living organisms. For the purposes of this questionnaire, please do not include disinfectants or cleaning products.

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Where are these records kept? ______________________________________________________________________

How long are records kept? ________________________________________________________________________

Please attach copies of all records of pesticide applications (from one school, or from the entire district) during the one year period from ______ (date) to ______ (date).

(OR, optionally) Please fill out the attached summary chart with product names, active ingredients, and total amounts of each pesticide product used in the past year. Please include any pesticides used in interior/structural settings, as well as in outdoor/landscape settings.

5. Pesticide Product Information: Does the school district have product labels and Material Safety Data Sheets (MSDSs) for all chemicals used on school property on file and available for public inspection?

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What about for products used by district contractors? ___________________________________________________

Please attach copies of labels and MSDSs for all products used (at one school, or throughout the district) during the one year period from _______ (date) to _______ (date).

Does the school district have information on the identity or toxicity of 'inert' ingredients in the pesticide products used on school property (if any)?

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6. Pesticide Applications: When and how often are pesticide applications done (on a schedule, or only when a pest problem is present)?

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What time of day and week are applications made? ______________________________________________________

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7. Pesticide Use Decisionmaking: Who makes the decision about whether to use pesticides?

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Is there a written record of reasons or criteria and justification for pesticide use? ______________________________

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Are preventive and non-chemical control methods considered, tried, and documented before pesticides are used?

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Is there an appeals process if parents, teachers or school staff wish to challenge proposed use of a pesticide?

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8. Notification and Posting: If pesticides are used, what is the school district's notification policy to parents?

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To teachers and other school staff? ___________________________________________________________________________________

Are treated areas posted? _________________________________________________________________________

Before or after applications, and for how long? ________________________________________________________

9. Protection of Sensitive Individuals: Are any students, teachers, or other school staff known to be especially sensitive to chemical exposures?

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What measures are taken to identify, notify, and protect these individuals if pesticides are used at school?

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10. Emergency Management: Does the school's emergency management plan address possible pesticide accidents or exposures due to on-site pesticide use or use on adjacent properties?

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Is the school nurse trained to recognize pesticide exposure symptoms? _____________________________________