WW-00915     Reviewed 1998  

Pesticide Application Record

Dean Herzfeld, Coordinator,
Minnesota Health, Environmental, and Pesticide Safety Programs

Farm:	Fertilization:
Field/Site:	Date Harvested:
Soil Type:	Yield:
Crop Last Year:	Notes:

The first eight items are required to be kept for two years by United States Department of Agriculture for all restricted use pesticide applications under the Food Agriculture Conservation and Trade (FACT) Act of 1990.

1. NAME AND CERTIFICATION NUMBER OF APPLICATOR:

MAKE A RECORD OF EACH APPLICATION OF EACH PESTICIDE
	App. # 1	App. # 2	App # 3	App. # 4	App. # 5
2. Field or Site Location/ID
3. Date (Mo., Day, Year)
4. Size of Area Treated
5. Pesticide Used (Brand Name)
6. EPA Registration Number
7. Total Amount Applied
8. Crop/Commodity or Site
9. Formulation
10. Additives
11. Method of Application
12. Stage of Crop Growth
13. Purpose of Application
14. Stage of Development of Pest
15. Soil Conditions
16. Temperature
17. Time of Day
18. Wind
19. Cloud Cover
20. Effectiveness

Instructions

This form can be used for recording pesticide applications for weed, insect, or disease control to a particular field or part of a field during a growing season. Farmers may find the record useful for evaluating results and planning future chemical treatments.

The United States Department of Agriculture now requires all applicators of Restricted Use Pesticides (RUP) to record certain information within 14 days of every RUP application. These records are required to be kept for two full years. An "*" is placed next to the USDA required RUP information.

1. *Name and certification number of applicator.
   
   
2. *Field or Site Location/ID—give name or location of the field or site (or the part of field) treated. See map section below.
   
   
3. *Date—fill in the month, day, and year of the application.
   
   
4. *Area treated—in acres, square feet, etc. If banding pesticides give total size of the field, not just the area actually treated in the band.
   
   
5. *Pesticide used—give product, trade, or brand name. Listing common names of active ingredients in the product is also often helpful.
   
   
6. *EPA registration number—from the pesticide label.
   
   
7. *Total amount applied—list total amount of formulated product (pounds, ounces, quarts, gallons, etc.) used on the total area treated given in 3 above.
   
   
8. *Crop or site—give the crop, commodity, stored product or site to which the pesticide was applied.
   
   
9. Formulation—use liquid (L), emulsifiable concentrate (EC), wettable powder (WP), granules (G), dust (D), soluble powder (SP), dry flowables (DF), or pellets (P).
   
   
   
   

   NORTH

   
   
10. Additives—indicate type and amount of any additives such as oils, spreaders, stickers, surfactants, wetting agents, detergents, or other adjuvants.
    
    
11. Method of application—broadcast, band, preplant, preemergence, postemergence, directed, aerial, airblast, and method of incorporation (if any), and implement used.
    
    
12. Stage of crop growth—use height in inches, number of leaves or other generally used description (tasseling, flowering, heading, etc.).
    
    
13. Purpose of application—give specific names of target weeds, insects, diseases, or other reason.
    
    
14. Stage of development of pest—for weeds, diseases and insects. List height of weeds, number of leaves; adult, larva, or nymph stage of insect; degree of infestation or percentage of plants infected.
    
    
15. Soil conditions—at time of treatment.
    
    
16. Temperature—self-explanatory.
    
    
17. Time of day—self-explanatory.
    
    
18. Wind—self-explanatory.
    
    
19. Cloud cover—self-explanatory.
    
    
20. Effectiveness—indicate good, fair, or poor. It is advisable to sometimes leave untreated check strips.

Follow the Keys to Pesticide Safety

READ THE LABEL ON EACH PESTICIDE CONTAINER BEFORE EACH USE. Follow all instructions, heed all precautions, and use protective clothing and equipment as required.

APPLY PESTICIDES ONLY AS DIRECTED. Follow label directions for time, rate, method and crop or site of application.

RINSE PESTICIDE CONTAINERS AT THE TIME OF USE. Follow required triple-rinse or pressure-rinse procedures.

STORE PESTICIDES IN THEIR ORIGINAL, LABELED CONTAINERS. Keep them out of the reach of children and irresponsible people.

RECYCLE RINSED PESTICIDE CONTAINERS. The Minnesota Department of Agriculture is working with local leaders in many counties throughout the state of Minnesota to provide pesticide container recycling programs.

Field or site Location and ID

For more information contact your local county extension office or the Minnesota Department of Agriculture.

Produced by Communication and Educational Technology Services, University of Minnesota Extension.

In accordance with the Americans with Disabilities Act, this material is available in alternative formats upon request. Please contact your University of Minnesota Extension office or the Extension Store at (800) 876-8636.