PWS Attachment 2_DD1532 Pest Mgnt Maint Record_final.pdf

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Country

POC/Unit:

Type in the date that the pesticide was applied. The preferred format is

YYYY-MM-DD (i.e.

2020-07-22).

The name of the country where the pesticide was applied should automatically populate based on the selection made in the "Country" cell above.

Select the DOEHRS base camp name from the drop down list below where the pesticide was applied. If the location is not listed, please type in the current name of the base camp.

Select the specific site of application from the drop down list where the pesticide was applied

(i.e. bldg #, activity name, etc.) . If the site is not listed, please type in the site of application.

Select the origin for why the pesticide was applied from the drop down list (i.e. work order, etc.).

Date Country Base Camp Site of Application Origin

Please complete this worksheet if the EPA Registration Number of the pesticide product applied was not found in the dropdown list of the Pesticides Applied worksheet.

Country POC/Unit:

Type in the date that the pesticide was applied.

The preferred format is

YYYY-MM-DD

(i.e. 2020-07-22).

The name of the country where the pesticide was applied should automatically populate based on the selection made in the "Country" cell above.

Select the DOEHRS base camp name from the drop down list below where the pesticide was applied. If the location is not listed, please type in the current name of the base camp.

Select the site of application from the drop down list. If the site of application is not listed, then type in the site of application.

The site of application is the specific location (i.e. bldg #, activity name, etc.) for this action.

Please select the origin from the drop down list. An origin is why you did the work: routine inspection, work request, surveillance, etc.

Select an operation from the drop down list. An operation is the type of work done (i.e. light trap, sticky trap, fly trap, caulking). If the operation is not listed, then type in the operation.

Select a target pest from the drop down list that you were attempting to survey or control by a nonchemical measure. If the target pest isn't listed, then write the target pest in the additional comments field.

Select the device name used for surveillance/nonchemical control from the drop down list below (i.e., CDC Light trap, Shannon trap). Type in the device name if not listed in the drop down list.

Type in the number of traps/devices used.

Select the unit of measure (if applicable), otherwise leave it blank.

Type in the size of the area inspected/serviced. It needs to be a number between 0 and 1000000. Use decimals if needed.

Select the appropriate unit of measure (i.e. square feet, meters, acres, etc.) related to the area inspected/serviced from the drop down list.

Type in the name of the person (i.e. applicator) performing the work described.

Type in your DoD FIFRA, DoD Non-FIFRA, or State Certification Number.

Please type in the exact time in which the operation took place at the site. The preferred format is hh:mm (i.e. 09:45).

Type in the total time invested by all applicators in the operation in hours (i.e. 1 or 0.5).

Provide additional comment(s) if needed.

Date Country Base Camp Site of Application/Surveillance Origin Operation Target Pest Surveillance/Nonchemical Device Used Number of traps/Units placed Units of Measure Area Inspected/Serviced Units of Measure for the Area Inspected/Serviced Applicator Name Applicator Certification # Time of Operation Total Time Invested in Hours Additional Comments

Please complete this worksheet for recording all surveillance, nonchemical, and animal control information.

If the EPA Registration Number is selected, the pesticide trade name will automatically populate in this column (i.e.

CONTRAC All-Weather Blox).

If the EPA Registration Number is selected, the product formulation will automatically populate in this column (i.e.

Pelleted/Tabletted).

If the EPA Registration Number is selected, the active ingredient percentage for the product will automatically populate in this column (i.e. 0.005).

Type in the amount of concentrate used for mixing. If the product does not require mixing and is ready to be used please select "N/A".

Select the appropriate units of measure related to the amount of concentrate from the drop down list (i.e. ounce, pound, etc.). If the product does not require mixing and is ready to be used

Type in the Final % Concentration in the Finished Product. If the product does not require mixing and is ready to be used please select "N/A".

finished product applied.

For products that are formulated as Aerosols, please indicate the number of can(s) used. This estimate will be useful in calculating the total Pounds of Active Ingredient (PAI) applied.

Select the appropriate units of measure related to the amount of finished product applied from the drop down list (i.e. ounce, pound, etc.).

Type in the name of the person (i.e.

John Doe) who applied the pesticide.

Type in the applicator's DoD FIFRA, DoD Non- FIFRA, or State Certification Number.

Type in the exact time in which the pesticide was applied at the site. The preferred format is hh:mm (i.e. 09:45).

Type in the total time invested by all applicators in the operation in hours (i.e. 1 or 0.5). Provide any additional comments.

Pesticide Trade Name Product Formulation Active Ingredient Percentage Amount of Concentrate Used for Mixing

Units of Measure for the Amount of Concentrate Used for Mixing

Final % Concentration in Finished Product

Amount of Finished Product Applied

Units of Measure for the Amount of Finished Product Applied Applicator Name

Applicator Certification # Time Pesticide was Applied Total Time Invested in Hours Additional Comments

CONTRAC All-Weather BloxPelleted/Tabletted 0.005 N/A N/A N/A 54 ounce John Doe OAE-096-10 9:45 1 TEMPO SC ULTRA Soluble Concentrate 11.8 8 milliliter 0.025 1 gallon John Doe OAE-096-10 10:00 1 Headboards and bedframes treated FINAL All-Weather Blox Pelleted/Tabletted 0.005 N/A N/A N/A 20 ounce Tom Smith A-310-11-0707 10:00 0.25 PT ULD BP-300 Contact InsULV Concentrate 19 3 fluid ounce 1 12 fluid ounce Tom Smith A-310-11-0707 13:00 1 Maxforce Ant Bait StationsImpregnated Material 1 N/A N/A N/A 6 each John Doe OAE-096-10 13:00 0.1 PT Wasp-Freeze Wasp & Aerosol 0.249 N/A N/A N/A 6 second Tom Smith A-310-11-0707 9:30 0.15 Maxforce Granular Fly BaitGranular 0.6 N/A N/A N/A 4 ounce Tom Smith A-310-11-0707 10:00 0.5 Roundup Pro Herbicide Soluble Concentrate 41 1 quart 1 25 gallon Tom Smith A-310-11-0707 14:00 2 Needed for security to inspect perimiter

Type in the pesticide trade name (i.e.

CONTRAC All-Weather Blox).

Type in the product formulation (i.e.

Pelleted/Tabletted).

Type in the active ingredient(s) listed on the product label (i.e.

Bromadiolone).

Type in the active ingredient percentage listed on the product label (i.e. 0.005).

Type in the amount of concentrate used for mixing. If the product does not require mixing and is ready to be used please select "N/A".

Select the appropriate units of measure related to the amount of concentrate from the drop down list (i.e. ounce, pound, etc.). If the product does not require mixing and is ready to be used

Type in the Final % Concentration in the Finished Product. If the product does not require mixing and is ready to be used please select "N/A".

finished product applied. For products that are formulated as Aerosols, please indicate the number of can(s) used. This estimate will be useful in calculating the total Pounds of Active Ingredient (PAI) applied.

Select the appropriate units of measure related to the amount of finished product applied from the drop down list (i.e.

ounce, pound, etc.).

Type in the name of the person (i.e. John Doe) who applied the pesticide.

Type in the applicator's DoD FIFRA, DoD Non-FIFRA, or State Certification Number.

Type in the exact time in which the pesticide was applied at the site. The preferred format is hh:mm (i.e. 09:45).

applicators in the operation in hours (i.e. 1 or 0.5).

For foreign/non-EPA registered products please submit an electronic copy or high resolution photo of the product label.

Pesticide Trade Name Product Formulation Active Ingredient Active Ingredient Percentage Amount of Concentrate Used for Mixing Units of Measure for the Amount of Concentrate Used for Mixing

Final % Concentration in

Amount of Finished Product Applied

Units of Measure for the Amount of

Applied Applicator Name Applicator Certification # Time Pesticide was Applied Total Time Invested in Hours Additional Comments

DuPont Advion Cockroach Bait Station Indoxacarb 0.5 N/A N/A N/A 5 each Tom Smith A-310-11-0707 16:15 0.25 Used to combat cockroaches resistant to hydramethylnon

Type in the size of the area inspected/serviced.

It needs to be a number between 0 and 1000000.

Use decimals if needed.

Select the appropriate unit of measure (i.e.

square feet, meters, acres, etc.) related to the area inspected/serviced from the drop down list.

Type in the name of the person (i.e.

applicator) performing the work described.

Type in the applicator's DoD FIFRA, DoD Non-FIFRA, or State Certification Number.

Please type in the exact time in which the operation took place at the site. The preferred format is hh:mm (i.e. 09:45) applicators in the operation in hours (i.e. 1 or 0.5).

Provide additional comment(s) if needed.

Area Inspected/Serviced

Units of Measure for the Area Inspected/Serviced Applicator Name Applicator Certification # Time of Operation Total Time Invested in Hours Additional Comments

80 square feet Miller, Glen AF-001-10-0198 8:45 0.1 780 square feet Miller, Glen AF-001-10-0198 16:10 1 Lots of scorpions present 4555 square feet Miller, Glen AF-001-10-0198 9:45 0.3 2 acre Cook, Richard PA-704174 17:35 0.2 5 hectare Cook, Richard PA-704174 13:15 0.75

Pest Management Report (DD Form 1532)/Pest Management Maintenance Record (DD Form 1532-1)

Instructions

This spreadsheet meets the DoDI 4150.07 (DoD Pest Management Program) and DoDI 6490.03 (Deployment Health) requirements for recording and reporting pest management operations and pesticide use during military deployments. The spreadsheet consists of the following worksheets:

Instructions; Pesticides Applied; New Pesticides Applied; Surveillance, Non-Chemical and Animal Control; and Example(s). The "Pesticides Applied" worksheet is populated with the EPA registration numbers and trade names of the pesticides approved by the AFPMB for DLA stockage and Contingency Usage as well as pesticides previously approved and applied during military deployments and reported on DD Form 1532's. The "New Pesticides Applied" worksheet allows the user to type in the EPA Registration Number and Pesticide Trade Name for pesticides that were applied but don't appear as a choice in the EPA Registration Number drop down list in the "Pesticides Applied" worksheet. Use the "Surv NonChemical Animal Control" worksheet for recording information related

Submit this spreadsheet by the 15th day after the end of each month. Complete a separate spreadsheet for each location (base camp, FOB, etc.). Follow this format when naming/saving each spreadsheet: YEAR_MONTH_RAW_CAMP (example: 2020_JUL_RAW_DAHLKE.xls). Please refer to the cells above each column header which explains what needs to be filled out for each of the 3 dha.apg.pub-health-a.mbx.pesticide-hotline@health.mil

When you are finished, save the spreadsheet as an Excel Macro-Enabled Workbook and send it to

Army: NIPRNet:

dha.apg.pub-health-a.mbx.pesticide-archival@health.mil

Navy: (Contingency) usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-pesticiderpts@mail.mil

Navy: (Shipboard) usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-pesticiderpts@mail.mil

Air Force:

Through your MAJCOM PMP

Joint Operations:

Submit the spreadsheet to the authority directed by your Theater Command mailto:dha.apg.pub-health-a.mbx.pesticide-hotline@health.mil mailto:dha.apg.pub-health-a.mbx.pesticide-archival@health.mil mailto:usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-pesticiderpts@mail.mil mailto:usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-pesticiderpts@mail.mil

Instructions