FLUE CURED RECORDS - GAP Connections
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FLUE CURED RECORDS
Operation &
Management
Nutrient
TAB 1
Operation and Nutrient Management
Included Records:
• Operation Records
• Field/Tract ID Records
• Greenhouse Fertilization Records
• Field/Tract ID Fertilization Records
• Animal Manure or Litter Application Records
Additional documents may be requested. See GAPC Certification Compliance Guide.Operation
2019OperationRecords
OperationRecords
Records
Contact Information
Farm Address:
City: State: Zip:
County:
Phone:
Email Address:
Primary Grower Name:
Grower ID: Grower Date of Birth: / /
Training Date:
Associated Grower Name:
Grower ID: Grower Date of Birth: / /
Training Date:
Associated Grower Name:
Grower ID: Grower Date of Birth: / /
Training Date:
Associated Grower Name:
Grower ID: Grower Date of Birth: / /
Training Date:
Associated Grower Name:
Grower ID: Grower Date of Birth: / /
Training Date:
1 | Operation & Nutrient ManagementOperation Records
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: ______________
Farm Infrastructure Type Total Number
Box Barns
Flue-cured Curing Barns
Rack Barns
Dark-fired Curing Barns
Air-cured Curing Barns
Outdoor Air-cured Curing Structures*
Open
Storage Facilities
Enclosed
Stripping Facilities
(Air and Fire Only)
Sand Reels/Tumblers
(Flue Only)
Leaf Loaders
(Flue Only)
Mechanical Tobacco Harvesters
* For outdoor curing structures, give total stick capacity for Total Number
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:
2 | Operation & Nutrient ManagementField/Tract ID Records
Field / Tract ID Farm Name or County FSA Number Tobacco Latest Soil Date of Last Rate of Lime
Location Acres Testing Date Lime Application (tons/acre)
3 | Operation & Nutrient ManagementGreenhouse Fertilization Records
Greenhouse ID Transplant Date Types of Fertilizer Rate
Number Batch Number (per 1,000/gallons)
4 | Operation & Nutrient ManagementField/Tract Fertilization Records
Rate of
Field/Tract ID* Date Application Timing Analysis (N-P-K) Application K20 from Muriate, if applied Muriate of Potash
(lbs./acre) after December 31 (lbs./acre) Date of Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
Pre-plant Transplanting
Side-dressing Foliar Application
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1
5 | Operation & Nutrient ManagementAnimal Manure or Litter Application Records
Date(s) Animal Manure Tested for Nutrient Content: _________________________________
Field/Tract ID* Date Type of Manure Rate
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1
6 | Operation &Nutrient ManagementIPM &
CPA
TAB 2
IPM & CPA
Included Records:
• Scouting Records
• CPA Applicator License Information
• CPA Information Records
• Greenhouse CPA Records
• Field/Tract CPA & Sucker Control Records
• Sprayer Calibration Records
Additional documents may be requested. See GAPC Certification Compliance Guide.Scouting Records
Follow-up on Pest
Field Control Practices to
Pest Identified Level of
Scouting Field/Tract ID* Corrective Actions Taken (Include Date of Action) Determine the
During Scouting Infestation of
Dates Effectiveness of
Pest Identified
Actions Taken
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1
1 | IPM and CPACPA Applicator License Information
List all the applicators and license numbers used on your farm operation below. If pesticide
applicator 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.
2 | IPM and CPACPA Information Records
Save Time: The Federal record keeping regulations require the certified private applicator to record the
brand/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.
Label SDS
Reference Brand EPA Registration Active Ingredient REI on on
Number Name Number (Hours) File File
“3” “3”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
3 | IPM and CPAGreenhouse CPA Records
Transplant Brand / Product
Greenhouse Batch Date Applicator* Name or Reference Reason for Application Rate / 1,000 Total Start /
ID Number Number Number** sq. ft.*** Application Finish Time
*Applicator or reference number from Tab 2 IPM and CPA Page 2
**CPA Information Records from Tab 2 IPM and CPA Page 3
***Total Amount of Product Used per 1000ft2 (indicate unit: oz., lb., pt., qt., gal.)
4 | IPM and CPAField/Tract CPA and Sucker Control Records
Field/ Brand / Product Size of Start /
Tract Name or Reference Rate / Acre Total Area Finish Method of
ID* Date Applicator** Reason for Application Number **** Application Treated Time Application
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
Hand
Sprayer
*Field/Tract ID from Tab 1 Operation & Nutrient Management Page 1
**Applicator or reference number from Tab 2 IPM and CPA Page2 ***CPA
Information Records from Tab 2 IPM and CPA Page 3
****Total Amount of Product Used (indicate unit: oz., lb., pt., qt., gal.)
5 | IPM and CPASprayer 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
Sprayer
Brand and
Model
Sprayer
Type
Nozzle Type
and Size
Pressure
Speed (mph)
Throttle
(rpm)
Tractor
Model
Tractor Gear
Spray
Volume
(gal/ac)
6 | IPM and CPAManagement
Crop
TAB 3
Crop Management
Included Records:
• Seed Selection Records
• Transplanting and Topping Records
• Weed Prevention Program
Additional documents may be requested. See GAPC Certification Compliance Guide.Seed Selection Records
Seed
*Required Selection
for Plants ProducedRecords
and Purchased
*Required for Plants Produced and Purchased
Variety Selection: Please list the resources or sources of information used to make variety selection decisions: ______________________________
Variety Selection: Please list the resources or sources of information used to make variety selection decisions:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Batch 2: Variety, Date Seeded:
Batch 1: Variety, Date Seeded: Batch 3: Variety, Date Seeded:
Transplant
Transplant Batch
Batch No.: No.:
The The transplant
transplant batch number
batch number is created
is created by you
by you and and is
is used to used to identify
identify each separate
each separate batch ofbatch of transplants
transplants used in your in your operation. A
used operation.
separate
A separate number
number shouldshould be given
be given to each each batch
to batch of transplants
of transplants of the of
same same source,
the source, variety,variety, lot number,
lot number, and seeded
and seeded at the same same
at thetime in time
the same same
in thegreenhouse.
greenhouse.
See diagram above ofSee diagram below
greenhouse bed. of greenhouse bed.
Greenhouse Transplant LC Variety
ID No.* Batch No. Seedling Source Variety Name Seed Lot # (Burley & Dark ONLY) Date of Seeding
Greenhouse Transplant Seeding Variety Seed LC Variety Date of
ID No* Batch No. □ Grown □ Purchased
Source Name Lot # (Burley
□ Yes& Dark ONLY)
□ No Seeding
□ Grown □ Purchased □ Yes □ No
Grown Purchased Yes
Y No
□ Grown □ Purchased □ Yes □ No
Grown □ Purchased
□Grown Purchased Yes
□Yes □ No
No
□ Grown □ Purchased □ Yes □ No
Grown Purchased Yes No
□ Grown □ Purchased □ Yes □ No
□ Grown □ Purchased Yes □ No
Grown Purchased □Yes No
□ Grown □ Purchased □ Yes □ No
Grown Purchased
□ Grown □ Purchased
Yes
□ Yes
No
□ No
Grown □ Purchased
□Grown Purchased Yes
□Yes □ No
No
□ Grown □ Purchased □ Yes □ No
*This Greenhouse ID number isGrown
created by Purchased Yes
you and is used to identify each separate greenhouse used in your operation. No
Grown Purchased Yes No
Grown Purchased Yes No
Grown Purchased Yes No
Grown Purchased Yes No
1 | Crop Management
*This Greenhouse ID number is created by you and is used to identify each separate greenhouse used in your operations.Transplanting and Topping Records
Plant Population (Plants/acre): ____________________ Row Spacing: ______________________ Plant Spacing in Row: ___________________
Topping Height
Field/Tract ID* Transplanting Transplant Date (approximate number of
Date Batch Number** of Topping leaves left)
* Field/Tract ID from Tab 1 Operation & Nutrient Management Page 1
** Transplant Batch No. from Tab 3 Crop Management Page 1
Program for Preventing Weed Seed Contamination of Harvested Leaf (Palmer Amaranth, other Pigweed, Ragweed, Grasses)
Herbicides used __________________________________________________________________________
Number of Cultivations _____________________ Control of weeds in field borders _____________________
Preharvest scouting and cleanup practices _____________________________________________________
2 | Crop Management
Other (hand hoeing, etc.) ___________________________________________________________________TAB 4
Management
and Barn
Curing
Curing & Barn Management — Flue
Included Records:
• Flue Curing Facility Records
• Flue Harvesting and Curing Records
Additional documents may be requested. See GAPC Certification Compliance Guide.Flue Curing Facility Records
GAP Connections Certification -- Barn Testing 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
Barn ID Barn Make and Heat Exchanger Initial Final Barn Status
Number Model Brand Reading Reading Pass / Fail
1 | Curing & Barn Mgmt.-FlueFlue Curing Facility Records (Retest Report)
GAP Connections Certification -- 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
Barn ID Barn Make and Heat Exchanger Initial Final Barn Status
Number Model Brand Reading Reading Pass / Fail
2 | Curing & Barn Mgmt - FlueFlue Harvesting and Curing Records
Field/Tract Harvest Date Method of Stalk Position Barn ID Fuel Source Bale ID Number(s)
ID** Harvesting
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
LP Fuel Oil
Natural Gas Other ________
3 | Curing & Barn Mgmt - Flue.TAB 5
Non-Tobacco Related Materials
Included Records:
Non-Tobacco
Materials
• NTRM Inspection Information
Related
(English & Spanish)
• NTRM Inspection Log
Additional documents may be requested. See GAPC Certification Compliance Guide.NTRM Inspection Information
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
Worker TrainingTips:
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.
1 | Non-Tobacco Related MaterialsInspección 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 dede
Consejos Capacitación
Capacitación para el para
Personal:
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.
2 | Non-Tobacco Related MaterialsNTRM Inspection Log
Regisstro de Inspección NTRM
Areas Inspected
Comments
(ex: market prep facilities,
(ex: No new sources of NTRM,
baling equipment, break areas)
Who did the added a trash can in break area)
Inspection? Areas Inspeccionadas
Comentarios
(ej: instalaciones de
(ej: No hay nuevas fuentes de
preparación del Mercado,
Date Quién hizzo la NTRM, se agregó un bote de
equipos de emaque,
Fecha inspección? basura al área de descanso)
áreas de descanso)
3 | Non-Tobacco Related MaterialsTAB 6
Agrochemical Storage and Soil & Water
Included Records:
• CPA Inventory Records
• Rainfall Records
• Irrigation Records
• Crop Rotation Records
Agrochemical
Soil & Water
Storage and
Additional documents may be requested. See GAPC Certification Compliance Guide.CPA Inventory Records
Reference Brand Name / Product / Common Name Storage Area Amount
Number*
*CPA Information Records from Tab 2 IPM and CPA Page 3
1 | Agrochemical Storage Soil & WaterRainfall Records
Rainfall records can be kept daily, weekly or monthly.
Field/Tract ID* Date Amount of Crop Condition
Precipitation
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1
2 | Agrochemical Storage Soil & WaterIrrigation Records
Irrigation records can be kept daily, weekly or monthly.
Field/ Date Source of Application Amount Crop Condition before Irrigating
Tract Irrigation Water Type Applied
ID*
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1
3 | Agrochemical Storage Soil & WaterCrop Rotation Records
20__ 20__ 20__ 20__
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
*Field/Tract ID from Tab 1 Operation & Nutrient Management Records Page 1 **
Tillage type indicates one of the following: conventional, strip-till, or minimum till
4 | Agrochemical Storage Soil & WaterTAB 7
Recruiting and Hiring Workers
Included Records:
• Labor Numbers
• DOL Template Terms & Conditions of Employment
(DOL WH-516)
• Worker Termination Record
• Non-Immediate Family Minors Working Record
and Hiring
Recruiting
Workers
Additional documents may be requested. See GAPC Certification Compliance Guide.Labor Numbers
Include all hired labor that steps foot on the farm and works in tobacco. This includes all part-time or
seasonal employees who may only work during peak time.
Workers Number of workers Number of workers Number of workers for
employed year-round employed seasonally whom housing is provided
H-2A Workers Hired Directly 1
Living on Farm
Not Living on Farm
H-2A Workers Hired Indirectly 2
Living on Farm
Not Living on Farm
Migrant Labor3
Migrant 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-immediate family, non-H-2A, non-migrant)4
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 Labor5
Year-round Seasonally
Living on Working on Living on Working on
the Farm the Farm the Farm the Farm
Immediate Family (18 or older)
Immediate Family Minors (16-17)
Immediate Family Minors (15)
Immediate Family Minors (14)
Immediate Family Minors
(13 or younger)
1
Hired Directly: Workers are hired directly by grower or with the assistance of a personal attorney, approved H-2A agent, or approved H-2A
agricultural association (i.e. NCGA, AWMA, VAGA, National Ag Consultants, and KY Farmers Aid).
2
Hired Indirectly: Workers are not hired directly by grower or with the assistance of a personal attorney, approved H-2A agent, or approved H-2A
agricultural association. Grower solicits a third-party such as a FLC or H-2ALC to hire workers to work on grower’s operation.
3
Migrant Labor: An individual who is employed in agricultural employment of a seasonal or other temporary nature, and who is required to be
absent overnight from his permanent place of residence.
4
Local Labor: Workers engaged in agriculture who commute daily from their permanent residence.
5
Immediate family members include only: (1) spouse; (2) children, stepchildren, and foster children; (3) parents, stepparents, and foster parents;
and (4) brothers and sisters. If the worker does not fall into one of these four categories, then the worker is considered a hired worker.
1 | Recruiting & Hiring WorkersMigrant and Seasonal Agricultural U.S. Department of Labor
Worker Protection Act Wage 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 there
are 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 sales
made 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.
Optional form WH516 ENG
Persons are not required to respond to this information unless it displays a currently valid OMB number. REV 06/14
2 | Recruiting & Hiring Workers3 | Recruiting & Hiring Workers
Worker Termination Record
Worker Name Reason for Termination Documentation
5 | Recruiting & Hiring WorkersNon-Immediate Family Minors (Under Age 18) Working on Farm Record
U.S. Certification: Hired workers under 18 are restricted from Department of Labor (DOL) Hazardous Tasks (For a list See Certification Standards Appendix 1 List A)
International Certification: Hired workers under 18 are restricted from International Restricted Tasks (For a list See Certification Standards appendix 1 List B)
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
6 | Recruiting & Hiring WorkersTAB 8
Workers Right & Responsibilities and
Worker Concern Helpline
Included Records:
• Worker Concern Process Documentation
(English & Spanish)
• Anti-Discrimination Policy
(English & Spanish)
WWR
WCH
and
Additional documents may be requested. See GAPC Certification Compliance Guide.Worker Concern Process Documentation
Worker Concern Process Documentation
Worker
Grower ID
ID##
Concern Process Documentation
Worker
Grower
Grower
ID#
GrowerName
Name
Concern Process Documentation
Grower
Grower ID#
Name
Farm
FarmName
Name
Grower
Farm Name
Trainer (s)
Trainer(s)
Farm Name
Trainer (s)
Date
Date
Trainer (s)
Date
• Information on the Worker Rights and Responsibilities and Worker Concern
• Date
Helpline poster
Information on thewasWorker sharedRights
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operator. 1 | WRR & WCHDocumento
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con el operador de la línea de ayuda.
2 | WRR & WCHWorker Concern Process Documentation
Documento Para El Proceso De Quejas
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.
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
3 | WRR & WCHAnti-Discrimination Policy
* _______________________________________ 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, leaves of absence, benefits,
and training.
* _______________________________________ seeks to comply with all applicable federal, state
and local laws related to discrimination.
* _______________________________________ makes decisions concerning employment
based strictly on an individual’s qualifications and ability to perform the job under consideration,
the comparative qualifications and abilities of other applicants or employees, and the individual’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.
There will be no retaliation against any employee who files a complaint in good faith, even if the result
of the investigation produces insufficient evidence to support the complaint.
*INSERT FARM NAME OR GROWER NAME
4 | WRR & WCHPolitica Antidiscriminación Borrador
* _______________________________________ 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, permisos para ausentarse, beneficios, y entrenamiento.
* _______________________________________ busca cumplir con las leyes locales, estatales y
federales relacionadas a la discriminación.
* _______________________________________ toma decisiones en cuanto a empleo basado
estrictamente en las calificaciones individuales y las capacidades de realizar un trabajo bajo
consideración, las calificaciones comparativas y habilidades de otros aplicantes o empleados,
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
el resultado de la investigación no tiene suficientes pruebas que apoyen la queja.
*NOMBRE DE LA GRANJA O AGRICULTAR
5 | WRR & WCHTAB 9
Housing, Sanitation and Transportation
Included Records:
• DOL Template Housing Terms & Conditions
(DOL WH-521)
• Vehicle Information Records
• Driver Information Records
• Vehicle Inspection Log
• Field Sanitation Inspection Log
Transportation
Sanitation and
Housing,
Additional documents may be requested. See GAPC Certification Compliance Guide.1 | Housing, Sanitation & Transportation
Vehicle Information
Vehicle Make/Model Year Annual Checklist
Valid Tags
Insurance
If required:
State Safety Inspection, Date: __________
Federal Safety Inspection, Date: ________
Valid Tags
Insurance
If required:
State Safety Inspection, Date: __________
Federal Safety Inspection, Date: ________
Valid Tags
Insurance
If required:
State Safety Inspection, Date: __________
Federal Safety Inspection, Date: ________
Valid Tags
Insurance
If required:
State Safety Inspection, Date: __________
Federal Safety Inspection, Date: ________
Valid Tags
Insurance
If required:
State Safety Inspection, Date: __________
Federal Safety Inspection, Date: ________
2 | Housing, Sanitation & TransportationDriver Information
Driver License Date on Doctor
Driver’s Name Driver License Number Expiration Date Certificate (if required) If FLC or FLCE
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
Certificate
Authorized to transport (FLC Only)
Authorized to drive
3 | Housing, Sanitation & TransportationVehicle
Vehicle Inspection
Inspection Log
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 parking
brake functional)
Windshield (free of cracks)
Windshield Wipers (operational)
Floors/Sides (passenger compartment
free of openings or defects)
Seats (securely fastened)
Exiting Capability (properly functioning
door 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, discharge
away from passenger compartment)
Comments:
Maintenance:
4 | Housing, Sanitation & TransportationField Sanitation Inspection Log
For operations with eleven (11) or more workers, employed during the past twelve months, at any one time,
engaged in hand-labor operations. Grower must provide proof of purchase or rental of hand washing facilities.
In the case where the grower owns the Field Sanitation (porta potty and/or hand washing) or the Field Sanitation
has been returned to a rental business, the Field Sanitation Log can be used as documentations to meet the
Field Sanitation Certification Standard.
Toilet Trash
Potable Water &
Paper Emptied
Soap
“3” “3” “3” “3” “3”
5 | Housing, Sanitation and TransportationTAB 10
Worker Training and Farm Safety
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 Training &
Farm Safety
Additional documents may be requested. See GAPC Certification Compliance Guide.
WorkerAttention: This form contains information relating to
OSHA’s Form 300 (Rev. 01/2004) employee health and must be used in a manner that
protects the confidentiality of employees to the extent Year 20__ __
possible while the information is being used for U.S. Department of Labor
Log of Work-Related Injuries and Illnesses occupational safety and health purposes. Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
You 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 health
care 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 to Establishment name ___________________________________________
use 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 this
form. If you’re not sure whether a case is recordable, call your local OSHA office for help. City ________________________________ State ___________________
Identify the person Describe the case Classify the case
CHECK ONLY ONE box for each case Enter the number of
(A) (B) (C) (D) (E) (F) based on the most serious outcome for days the injured or Check the “Injury” column or
Case Employee’s name Job title Date of injury Where the event occurred Describe injury or illness, parts of body affected, that case: ill worker was: choose one type of illness:
no. (e.g., Welder) or onset (e.g., Loading dock north end) and object/substance that directly injured
Remained at Work (M)
of illness or made person ill (e.g., Second degree burns on
Away On job
right forearm from acetylene torch) from transfer or
Days away Job transfer Other record-
Death from work or restriction able cases restriction
Injury
work
Skin disorder
Respiratory
condition
Poisoning
Hearing loss
All other
illnesses
(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)
_____ ________________________ ____________ __
____/___
_______ __________________
____ ___________________
_______________________________
_ ■
❑ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ________________________________
__________________
_ ■
❑ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________
____________________________
_ ■
❑ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________
____________________________
_ ■
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❑ ■
❑ ■
❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ___________________
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_ ■
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❑ ■
❑ ■
❑ ____ days ____ days
month/day
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____/___
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__ ■
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❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________________
____________________
__ ■
❑ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________________
____________________
__ ■ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
❑
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________________
____________________
__ ■ ■
❑ ■
❑ ■
❑ ____ days ____ days
month/day
❑
_____ ________________________ ____________ __
____/___
_______ ___________________ ___________________
_______________________________
__ ■ ■ ■
❑ ■
❑ ____ days ____ days
month/day
❑ ❑
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________________
____________________
__ ■ ■ ■
❑ ■
❑ ____ days ____ days
month/day
❑ ❑
_____ ________________________ ____________ __
____/___
_______ ___________________ ______________________________
____________________
__ ■ ■ ■
❑ ■
❑ ____ days ____ days
month/day
❑ ❑
_____ ________________________ ____________ __
____/___
_______ __________________
____ ___________________
_______________________________
__ ■ ■ ■ ■ ____ days ____ days
month/day
❑ ❑ ❑ ❑
Page totals
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Injury
the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required
illnesses
All other
condition
Poisoning
to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments
Respiratory
Hearing loss
Skin disorder
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. Page ____ of ____ (1) (2) (3) (4) (5) (6)
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