Recordkeeping Form for the Worker Protection Standard and the USDA Restricted-Use Pesticides Regulation
Maintain records of all agricultural-use (WPS) and restricted-use pesticide applications for a minimum of 2 years.

/ USDA (1) Field ID/Location of Treated Area                                       			         

/ USDA			USDA	/ USDA	/ USDA	 	USDA	USDA	USDA	
(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	
Date (mo/day/yr)	Time
Planned	Restricted
Entry
Interval
(REI)	Crop or
Commodity
Treated	Brand Name(s)	EPA
Registration
Number(s)	Active
Ingredient(s)	Size of
Area
Treated	Total
Amount
Applied*	Applicator’s
Name &
Certification Number	
	Time
Completed									
	AM									

	PM									

	AM									

	PM									

	AM									

	PM									

	AM									

	PM									

	AM									

	PM									

	AM									

	PM									

	AM									

	PM

										
										
	AM									

	PM									

 This hand/head symbol indicates Worker Protection Standard (WPS) information (items 1-4 and 6-8). This information (except time completed) must be posted before pesticide application and remain posted for 30 days after the end of the Restricted Entry Interval (REI). After this time, the records must be maintained for 2 years. All other information (items 9-11) must be recorded within 14 days of application. If you apply a tank mix of pesticides with different REIs, write down the longest REI. 
Note: WPS agricultural-use pesticides may be general-use or restricted-use.

*Multiply the rate of application that you used by Size of Area Treated (item 9) to get Total Amount Applied (item 10). The Total Amount Applied is not the quantity after water or a carrier is added.

Note: For applications made to less than 1/10-acre, indicate “spot treatment” within Crop or Commodity Treated (item 5) and record the Location of Treated Area (item 1). Record the Date, Brand Name, EPA Reg. No., and Total Amount Applied (items 2, 6, 7, and 10).

Developed by Wayne G. Buhler, Ph.D., NC State University, in collaboration with the Structural Pest Control and Pesticides Division, NCDA&CS.     
AG-689W, E08-50268